【作者】 吴运芹；

【导师】 薄涛；

【作者基本信息】 中南大学 ， 儿科学， 2010， 硕士

【摘要】 目的早产儿由于肾上腺发育不成熟,在急症及应激状态下下丘脑-垂体-肾上腺轴(HPA)轴功能变化规律尚未明了。本研究通过观察疾病应激对早产儿的HPA轴相关激素的影响,以血清皮质醇、醛固酮、促肾上腺皮质激素(ACTH)水平作为监测指标,观察其变化规律,为临床选择合适时机合理应用糖皮质激素治疗提供参考。方法出生72小时内转入湖南省儿童医院新生儿科早产儿90例(胎龄<37周),排除遗传代谢性疾病,母孕期及患儿出生时均未用过糖皮质激素,以胎龄34周为界,分为胎龄≥34W组及胎龄<34W组,在入院时、日龄7天、14天行新生儿危重症评分,取最低值进行分组,分为危重组,非危重组；全部患儿分别在入院时(日龄72小时内)、日龄7天、14天静脉采血,留取血标本,分离血清,-70℃低温冰箱内保存待测,采用放射免疫法检测血清皮质醇、ACTH、醛固酮水平。结果(1)危重组血清皮质醇浓度均高于非危重组。日龄≤72小时胎龄≥34W早产儿危重组与非危重组比较,差异有显著性(t=-2.263,P=0.029)；日龄14天胎龄<34W早产儿危重组与非危重组比较,差异有显著性(t=-2.913,P=0.006)。(2)胎龄≥34W早产儿血清皮质醇浓度随日龄显著下降(F=4.679,P=0.012),胎龄<34W早产儿皮质醇浓度随日龄变化差异无显著性。(3)死亡病例生后14天血清皮质醇浓度较非死亡病例明显增高(P<0.05)。(4)氧合指数(PO2/FiO2)与血清皮质醇浓度呈线性负相关,氧合指数越低,皮质醇升高水平越高(r=-0.466,P=0.001)。低血清皮质醇浓度与发病率及死亡率没有明显关系。血清皮质醇值在上四分位组(P75之上)时,机械通气、危重患儿比例、糖代谢紊乱、消化道出血、Ⅲ-Ⅳ级脑室周围-脑室内出血及脑软化、CLD、死亡发生率增加。(5)血清醛固酮、ACTH浓度与胎龄、疾病严重程度及多种临床因素之间进行统计学分析,无显著性差异。结论1、在早产儿中,应激发生时机体已具有调节皮质醇分泌的能力,胎龄越大,这种能力越成熟。2、血清皮质醇浓度增高与疾病的严重程度、并发症及预后密切相关。3、血清醛固酮、ACTH浓度与疾病的严重程度无显著相关性。更多还原

【Abstract】 Objective:In the state of emergency and stress, it is still unknown for their immature adrenal gland function how to change in preterm infant. To investigated the effect of illness on preterm infant’s hypothalamus-putituary-adrenal (HPA) axis and weather to use glucocorticoid (GC), we measured the serum concentration of cortisol, aldosterone and adrenocorticotropic hormone (ACTH).Methods:Ninety preterm infants transferred to our hospital within 72 hours after birth, excluding genetic metabolic diseases, and the application of GC during perinatal period. These preterm infants were divided into two groups:gestational age (GA)≥34weeks’preterm infants and GA<34weeks’preterm infants. We collected their clinical data and measure serum cortisol, aldosterone and ACTH by radio immunoassay method within 72 hours after birth, day 7 and day 14 after birth.Results:(1) The serum cortisol concentration on severe illness preterm infant was higher than that on mild illness preterm infant. Among the GA≥34weeks’preterm infants, the serum cortisol concentration on severe illness infants was significantly higher than on mild ill infants within 72 hours after birth (t=-2.263, P=0.029).Among the GA<34 weeks’preterm infants, the serum cortisol concentration on severe illness infants was significantly higher than on mild ill infants on the day 14 after birth (t=-2.913, P=0.006). (2) The serum cortisol concentration was significantly decreased on 7d and 14d after birth than that within 3d after birth in the GA≥34weeks’preterm infants (F=4.679, p=0.012);, the serum cortisol concentrations weren’t similar among different time points in the GA<34 weeks’preterm infants. (3) The serum cortisol concentration in death preterm infants was significant higher than that in survivor on 14d after birth. (4) Oxygen index (PO2/FiO2) was negatively correlated with serum cortisol concentration (correlation coefficient=-0.466, P=0.001). Low serum cortisol concentrations was not associated with increased morbidity and mortality.The serum cortisol concentrations of preterm infants with mechanical ventilation therapy and upper gastrointestinal hemorrhage were significantly higher than those of infants without mechanical ventilation therapy or no gastrointestinal hemorrhage (P<0.05). When the serum cortisol concentration was above the 75th percentile (P75), the incidence of mechanical ventilation therapy,glucose metabolism disorder, gastrointestinal hemorrhage,Ⅲ-Ⅳgrade periventricular-intraventricular hemorrhage and brain leukomacia, chronic lung disease, and mortality rate were increased strikingly. (5) Serum aldosterone and ACTH concentration were not modified by a variety of perinatal factors, such as gestational age, illness severity, and complication. Conclusions:1、The preterm infant already has the ability to response stimuli by regulating cortisol secretion. The greater the gestational age is, the more mature this ability is.2、The serum cortisol concentration is correlated with the severity of the disease, complications and prognosis.3、Serum aldosterone and ACTH concentration are not correlated with the severity of the disease.更多还原