日本未熟児新生児学会雑誌　第24巻第1号　109～113頁（2012年）

日本未熟児新生児学会雑誌　24(1)：109-113；2012　

受付日：平成23．05．25

受理日：平成23．07．28

新生児失血性疾患に対する初期輸液療法の検討

Initial Fluid Management for Perinatal Blood Loss

＊1石川県立中央病院　いしかわ総合母子医療センター　新生児科，＊2石川県立中央病院　いしかわ総合母子医療センター　小児内科

＊1Department of Neonatology, Ishikawa Medical Center for Maternal and Child Health, Ishikawa Prefectural Central Hospital，＊2Department of Pediatrics, Ishikawa Medical Center for Maternal and Child Health, Ishikawa Prefectural Central Hospital

上野康尚＊1・中田裕也＊1・北野裕之＊1・西尾夏人＊2・堀田成紀＊2・久保　実＊1＊2

Yasuhisa UENO＊1，Yuya NAKADA＊1，Hiroyuki KITANO＊1，Natsuhito NISHIO＊2，Seiki HORITA＊2，Minoru KUBO＊1＊2

Key Words：perinatal blood loss，hemorrhagic shock，fluid management

　新生児期，特に分娩前後では種々の病態で血液喪失が起こり循環血液増量剤の投与が考慮される。新生児蘇生法では，まず10mL/kgの生理食塩水を5～10分かけて投与し，反応が不良な場合，同量を投与することが推奨されている。しかし，その後の輸液量，輸液速度を明確に示した指針は少ない。そこで我々が経験した8症例について，最初の1時間の輸液療法に焦点を当てて，臨床背景，転帰との関連を後方視的に検討した。最初の1時間に4.2～39.0mL/kgの輸液が行われた。帽状腱膜下出血1例（13mL/kg/1時間）が死亡し，胎盤血管断裂1例（22mL/kg/1時間）がMRIで脳虚血病変を認めた。他の6例は神経学的後遺症なく生存した。失血が持続していなくとも最初の1時間に40mL/kg前後，あるいはそれを超える輸液が必要な症例が存在することを示した。効果的で安全な輸液療法を行うには，治療効果を繰り返し評価することが重要である。

Backgrounds：Loss of blood volume in the neonate can occur via several mechanisms before, during, or after delivery. Volume expansion should be considered when blood loss is known or suspected（pale skin, poor perfusion, weak pulse） and the baby’s heart rate has not responded adequately to other resuscitative measures. Current neonatal resuscitation guidelines recommend that the initial fluid should be 10mL/kg isotonic saline as a bolus over 5 to 10 minutes and repeated doses should be based on individual clinical response. The amount of fluid needed is often difficult to predict in the neonatal hypovolemic settings. Few studies have examined the efficacy of repeated volume infusions. We don’t know what the optimal amount to give and at what the infusion rate is.
Objectives：Given these considerations and paucity of data available regarding the use of volume infusion, we undertook this study to examine the association of the volume of fluid administered at 1 hour after presentation, with outcomes.
Results：Eight cases with perinatal blood loss treated in Ishikawa Prefectural Central Hospital from 2006 to 2009 were retrospectively analyzed regarding the clinical features, the methods of fluid management and the outcomes. These included 2 cases of gastric bleeding, one case each of fetofetal hemorrhage, umbilical rupture, fetomaternal hemorrhage, subgaleal hemorrhage, abruptio placenta and placental incision. Every patient received from 4.2 to 39.0 mL/kg fluid resuscitation at 1 hour. The infant with subgaleal hemorrhage was died by hepatic failure on 60 day. The placental incision case received brain hypothermia, and showed parasagittal injury on brain MRI. Other 6 cases survived without neurological deficits.
Conclusion：Rapid fluid resuscitation in excess of 40 mL/kg in the first hour may be needed even when blood loss ceased. Frequent reassessment the clinical response is essential for effective and safe management of this potentially fatal perinatal complication.