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导读：2023年11月美国心脏协会与美国儿科学会根据新的临床证据，联合发布了新生儿复苏指南要点更新，该更新是对《2020美国心脏协会心肺复苏和心血管急救指南：新生儿复苏》的重要补充。该文旨在概述此次更新要点，为新生儿复苏中关于脐带管理以及正压通气设备及其附加接口的选择提供指导。期待您的关注与指导！
指南解读
DOI：10.7499/j.issn.1008-8830.2311107
祝甜 史源
第一作者：祝甜，女，本科，主治医师。重庆莱佛士医院儿科。
通信作者：史源，男，主任医师，教授。重庆医科大学附属儿童医院新生儿诊治中心/国家儿童健康与疾病临床医学研究中心/儿童发育疾病研究教育部重点实验室/儿科学重庆市重点实验室。2023年11月美国心脏协会与美国儿科学会根据新的临床证据，联合发布了新生儿复苏指南要点更新，该更新是对《2020美国心脏协会心肺复苏和心血管急救指南：新生儿复苏》的重要补充。该文旨在概述此次更新要点，为新生儿复苏中关于脐带管理以及正压通气设备及其附加接口的选择提供指导。
关键词：复苏；脐带结扎；正压通气；美国心脏协会；美国儿科学会；新生儿1 前言
近期国际复苏联络委员会（International Liaison Committee on Resuscitation）新生儿生命支持学组对足月儿、晚期早产儿和胎龄<34周早产儿的脐带管理以及新生儿复苏时正压通气（positive-pressure ventilation, PPV）的设备和接口选择进行了系统回顾[1-4]。2023年11月，美国心脏协会与美国儿科学会（American Academy of Pediatrics, AAP）在这些系统回顾的基础上，发布了新生儿复苏指南要点更新[5]。这次更新是对《2020美国心脏协会心肺复苏和心血管急救指南：新生儿复苏》[6]（以下简称《2020指南》）的重要补充。本次更新的主要内容包括新生儿复苏中的脐带管理、PPV的设备及其附加接口的选择，为参与分娩和新生儿救治的医护人员提供新的指导，进一步完善了新生儿复苏这项重要的生命支持技术。现将本次更新内容总结如下。
(1) 对于胎龄≥34周不需复苏的足月儿与晚期早产儿，延迟脐带结扎（≥30 s）比早期脐带结扎（<30 s）更有益。(2) 对于胎龄≥34周不需复苏的足月儿与晚期早产儿，脐带挤压与延迟脐带结扎（≥30 s）相比并无益处。(3) 对于无活力的足月儿与晚期早产儿（胎龄35~42周），脐带挤压比早期脐带结扎（<30 s）可能更合理。(4) 对于胎龄<34周不需复苏的早产儿，延迟脐带结扎（≥30 s）比早期脐带结扎（<30 s）更有益。(5) 对于胎龄28~34周不需复苏的早产儿，不能进行延迟脐带结扎（≥30 s）时，可采用脐带挤压。(6) 对于胎龄<28周的早产儿，不建议脐带挤压。(7) 对于出生后需要复苏的新生儿，有效的PPV是首要任务。(8) 使用T组合复苏器提供PPV比使用自动充气式气囊（self-inflating bag）更可取。(9) 由于T组合复苏器和气流充气式气囊（flow-inflating bag）都需要压缩气源才能发挥作用，因此在使用这两种设备时，都应准备一个自动充气式气囊作为压缩气源失效时的备用。(10) 对于胎龄≥34周的新生儿，可考虑由声门上气道（supraglottic airway）（主要为喉罩）替代面罩，作为PPV的接口。2 建议等级与证据级别
本次更新中的建议等级（class of recommendation）及证据级别（level of evidence）见表1。本次共更新8项推荐意见，其中5项的证据级别是B-R级，1项是B-NR级，2项是C-LD级；其中3项推荐意见的建议等级为2a级（中），3项2b级（弱），2项3级无益（中）。
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3 脐带管理
分娩时的脐带管理及脐带输血是一个仍需大力研究的领域。从胎盘转移到新生儿的血量以及胎盘输血的效果因多种因素而异，如胎龄、脐带结扎时间、是否脐带挤压以及新生儿的生理状态。
美国妇产科医师协会与AAP均制定了关于脐带管理的指南[7-8]。《2020指南》也提及了脐带管理[6]，但未对不同胎龄新生儿提出更细化的建议。由于早产儿与足月儿之间客观存在的发育差异，不同胎龄新生儿为达到最佳预后，必然需要采取不同的脐带管理策略。为进一步优化脐带管理策略，国际复苏联络委员会进行了2次系统综述，其中1次针对晚期早产儿/足月儿[1]，另1次针对胎龄<34周早产儿[2]。本次更新针对这两个群体提出了6项推荐意见，见表2和表3。![]()
4项随机对照试验（randomized controlled trial, RCT；n=537）发现延迟脐带结扎与否对于足月儿和晚期早产儿，病死率差异无统计学意义[9-12]。来自15项研究（n=2 641）的数据显示，延迟脐带结扎与早期脐带结扎相比，可使血液学指标（血红蛋白、血细胞比容）增高[10-11,13-25]。一项包含1 730例无活力新生儿（胎龄35~42周）的RCT，比较了脐带挤压与早期脐带结扎对新生儿重症监护病房入住率的影响，结果发现差异无统计学意义。然而，在提升血红蛋白、降低心肺支持的需求方面，脐带挤压成为这一群体的合理选择[26]。未来更多的研究将有助于进一步评估这一干预措施。对于不需要复苏的足月儿及晚期早产儿，目前尚无证据表明，脐带挤压比延迟脐带结扎更有益。![]()
表3中推荐意见的依据如下。
16项RCT（n=2 988）显示，与早期脐带结扎相比，延迟脐带结扎的新生儿出院后存活率有所提高。其中延迟脐带结扎的时间从30 s至2 min不等[27-42]。6项研究（n=351）显示，延迟脐带结扎的新生儿在生后第1天肌力药物的使用减少[36,39-41,43-44]。延迟脐带结扎的新生儿，在生后第1天和第7天，血液学指标有所改善[27-30,34-46]，入院期间输血次数减少[27,30-31,35,38,40-43,45-47]。
与早期脐带结扎相比，在11项研究（n=983）中，脐带挤压的新生儿在生后第1天的血液学指标较高[46,48-58]。在5项研究中（n=439），脐带挤压的新生儿在生后第1天肌力药物的使用减少[40-50,52,58]。在10项研究中（n=889），对于胎龄28~32周的早产儿，无法判断脐带挤压对严重脑室内出血的影响[46,48-50,52,54-56,58-59]。
一项对292例早产儿（胎龄28~31+6周）的研究显示，与延迟脐带结扎相比，脐带挤压不会增加严重脑室内出血的风险[60]。
在一项对182例无需复苏的早产儿（胎龄23~27+6周）的研究中发现，脐带挤压的早产儿发生严重脑室内出血的风险显著增高[60]。4 通气支持：PPV的设备与接口
可实施PPV的设备包括自动充气式气囊、气流充气式气囊和T组合复苏器。PPV设备的选择取决于多个因素：分娩胎儿个数、病例临床情况、压缩气源的可用性、对不同设备的培训及熟悉度、设备成本。由于T组合复苏器和气流充气式气囊需要压缩气源才能发挥作用，因此在使用这两种设备时，都应准备一个自动充气式气囊作为压缩气源失效时的备用。
《2020指南》提供了何时以及如何使用PPV的建议，包括对于充气压力、呼气末正压的使用、通气频率以及吸气时间的指导[6]。本次更新着重讨论提供PPV的设备以及实施PPV时接口的选择，其推荐意见如下。
推荐意见1：在使用PPV设备进行新生儿复苏时，T组合复苏器（不论是否带有呼末正压阀）比自动充气式气囊更可取，尤其是早产儿。该项推荐意见的建议等级为2a级（中），证据级别为B-NR级。
该项推荐意见的依据包括:（1）对4项RCT（n=1 247）进行的Meta分析发现，与自动充气式气囊相比，使用T组合复苏器可缩短PPV持续时间，降低支气管肺发育不良的风险[3]，使用T组合复苏器可能对早产儿最有益；（2）系统回顾未发现评估气流充气式气囊使用情况的研究[4]。
推荐意见2：对于胎龄≥34周的新生儿，实施PPV时，使用声门上气道替代面罩，可能是合理的。该项推荐意见的建议等级为2b级（弱），证据级别为C-LD级。
该项推荐意见的依据是一项对6个RCT（n=1 823，胎龄≥34周）进行的Meta分析，发现使用声门上气道降低了产房气管插管率[4]，PPV的持续时间和心率达到100次/min的时间也更短。根据现有证据，该项推荐意见仅限于胎龄≥34周的新生儿。纳入此Meta分析的所有研究都是在资源有限的医疗环境中进行的。没有研究比较过在高资源环境中（具备更多高级技能的医护人员或训练有素的新生儿复苏团队）新生儿复苏期间启动PPV时，使用面罩和声门上气道的情况。因此，此Meta分析可能无法适用于高资源环境。
5 有待探索的问题
综上所述，本次新生儿复苏指南更新为新生儿复苏时的脐带管理以及实施PPV的设备及其接口选择提供了新的指导。但更新的8项建议中，没有A级高质量证据，也没有1级（强）推荐。其中有争议或尚缺乏依据的问题，仍需要更多高质量的研究提供科学依据。提出以下有待进一步探索的问题，期待为新生儿复苏指南的不断更新提供更多循证依据。(1) 脐带管理：①对需要复苏的足月儿、晚期早产儿和胎龄<34周早产儿，脐带的最佳管理策略；②所有脐带管理策略的远期预后数据，如婴儿期贫血、神经发育结果。(2) PPV设备：①T组合复苏器与自动充气式气囊的成本效益比较；②带呼气末正压阀的自动充气式气囊对早产儿预后的影响；③使用T组合复苏器（或自动充气式气囊）与气流充气式气囊进行PPV复苏的比较；④按胎龄划分的、使用各种PPV设备的临床预后比较。(3) PPV的接口：①高资源环境中启动PPV时，声门上气道与面罩的比较；②成功插入声门上气道所需的训练量、训练类型，以及技能衰退的可能性；③经声门上气道吸出气道分泌物的实用性；④需要胸外心脏按压或气管内给药时，使用声门上气道的效果。
作者贡献：祝甜参与选题与设计，负责资料收集和分析，以及论文撰写；史源负责论文选题与设计，以及论文审阅、修改。
利益冲突声明：所有作者声明无利益冲突。
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