换血技术治疗新生儿高胆红素血症相关问题的多中心回顾性调查

Exchange transfusion for neonatal hyperbilirubinemia:a multicenter retrospective survey

目的调查河北省因高胆红素血症接受换血治疗新生儿的临床特征、危险因素及换血技术相关问题。方法由河北省18家地市级三级医院组成多中心新生儿换血研究协作组,采用回顾性研究方法,收集2017年1月1日至2019年12月31日间各协作医院收治的因高胆红素血症接受换血治疗的533例新生儿住院期间的临床资料,根据入院日龄分为早期新生儿(<7 d组,n=387)和晚期新生儿(≥7 d组,n=146),应用Pearsonχ2检验或秩和检验分析2组患儿高胆红素血症的危险因素、换血技术相关问题及并发症。结果纳入533例,患儿胎龄(38.5±1.7)周,其中464例(87.1%)为足月儿,胎龄34~36周^(+6)者59例(11.1%),胎龄<34周10例(1.9%);男287例(53.8%);入院日龄4.5 d(2.0~7.0)d。533例纳入患儿共接受547次换血,早期新生儿(入院日龄<7 d)组高胆红素血症危险因素以免疫性溶血为主[64.6%(250/387)与31.5%(46/146)],而晚期新生儿(入院日龄≥7 d)组以不明原因[48.6%(71/146)与12.9%(50/387)]及非溶血性疾病[41.1%(60/146)与29.2%(113/387)]为主(χ^(2)值分别为47.013,77.036,6.844,P值均<0.05)。纳入病例换血前血清总胆红素中位值为432.0μmol/L(349.5~494.0μmol/L),换血后下降为215.1μmol/L(173.3~257.7μmol/L)(Z=1.000,P<0.05),胆红素换出率中位值为47.5%。除1例患儿应用全血换血外,其余532例中,298例(56.0%)换血采用2~3∶1的球浆比例。401例(75.2%)患儿换血前常规应用了白蛋白,318例(59.7%)患儿换血过程中给予了葡萄糖酸钙输注。换血最常见的并发症是血常规和生化检查异常,其中血小板减少症最为常见(43.7%,233/533),换血前中位血小板计数为[297(233~363)]×10^(9)/L,换血后为[105(82~140)]×10^(9)/L(Z=1169.5,P<0.05);其他依次为高血糖、低钾血症、低钙血症等。严重并发症发生率为6.9%(37/533),以呼吸暂停为主,未观察到换血相关的死亡发生。共有241例(45.2%)诊断急性胆红素脑病。结论达到换血标准的新生儿高胆红素血症患儿中,早期与晚期新生儿的常见危险因素存在差异。换血可有效降低血中胆红素水平,但存在一定风险,应及时识别高危因素避免严重高胆红素血症发生,临床换血流程亟待规范。

Objective To explore and analyze the clinical characteristics,risk factors of neonates receiving exchange transfusion(ET)for hyperbilirubinemia and problems associated with ET in Hebei Province.Methods The clinical data of 533 neonates who received ET for hyperbilirubinemia were retrospectively collected from the Multicenter Exchange Transfusion Collaborative Group that formed by 18 hospitals at prefecture-level or above in Hebei Province from January 1,2017,to December 31,2019.According to the age at admission,all subjects were divided into<7 d(n=387)and≥7 d groups(n=146).The risk factors of hyperbilirubinemia were analyzed by Pearson Chi-square test between the two groups.The related problems and complications of ET were summarized and compared using rank sum test.Results There were 533 neonates with hyperbilirubinemia receiving a total of 547 ETs during the period,with an average gestational age of(38.5±1.7)weeks,among which 287(53.8%)were male infants.Totally,87.1%(464/533)neonates were born at full-term,11.1%(59/533)at 34-36^(+6) weeks and 1.9%(10/533)at<34 weeks.The average age on admission was 4.5 d(2.0-7.0)d.The main risk factors of hyperbilirubinemia were hemolytic disease[64.6%(250/387)vs 31.5%(46/146)]in the<7 d group,whereas were unexplained reasons[48.6%(71/146)vs 12.9%(50/387)]and non-hemolytic diseases[41.1%(60/146)vs 29.2%(113/387)]in the≥7 d group(χ^(2)=47.013,77.036,6.844,respectively,all P<0.05).The median total bilirubin level decreased significantly from 432.0μmol/L(349.5-494.0μmol/L)before ET to 215.1μmol/L(173.3-257.7μmol/L)after(Z=1.000,P<0.05).The median bilirubin transfusion rate was 47.5%.In 259(56.0%)out of the 532 cases using red blood cell and plasma for ET,the reconstituted packed red blood cells and plasma ratio was 2-3∶1.Albumin was routinely administered in 401(75.2%)cases before ET and calcium gluconate in 318(59.7%)cases during ET.The most common adverse events after ET was thrombocytopenia(233/533,43.7%)and the platelet count before and after ET were[297(233-363)]×10^(9)/L and[105(82-140)]×10^(9)/L,respectively(Z=1169.5,P<0.05),followed by hyperglycemia,hypokalemia,and hypocalcemia,etc.The severe adverse events were accounted for 6.9%(37/533)and apnea was the leading one.No death was reported due to ET.A total of 241 cases(45.2%)were diagnosed as acute bilirubin encephalopathy.Conclusions Risk factors for ET are different between the early and late newborns with hyperbilirubinemia who meet the criteria for ET.ET can reduce the level of bilirubin,but with some potential risks.Therefore,it is necessary to identify the high-risk factors as soon as possible to avoid severe hyperbilirubinemia.A standadized protocol for ET should be developed and followed.