Filiz EKİCİ, Sevim ÜNAL, M. Yekta ÖNCEL, Leyla BİLGİN, İ. İlker ÇETİN, Mehmet GÜNDÜZ

Önceden Sağlıklı Olan Yenidoğanlarda Gelişen Metabolik Asidoz Nedenleri ve Prognoz

Amaç: Yenidoğanlarda perinatal asfiksi sonucu oluşan metabolik asidoz dışında, geç metabolik asidoz ciddi hastalıklar nedeniyle oluşmakta ve geriye dönüşümsüz sonuçlara neden olabilmektedir.Metod: Yenidoğan ünitemize yatırılan, perinatal asfiksisi olmayan, gestasyon yaşı >35 hafta olup şok bulgularıyla başvuran yenidoğanlar retrospektif olarak değerlendirildi. Başvuru sırasında arteriyel pH≤7.30, HCO3≤16 mmol/L, baz açığı≥8 mmol/L olup NaHCO3 infüzyonu uygulananlar çalışmaya alındı. Etiyolojik nedenler, kan gazlarına NaHCO3 infüzyonunun etkisi ve prognozu etkileyen faktörler incelendi.Bulgular: Hastanemize Ekim 2009/Eylül 2010 tarihlerinde yatırılan 1284 yenidoğandan 32 term ve geç prematürede başvuruda şok bulguları olup geç metabolik asidoz nedeniyle NaHCO3 defisiti verilmişti. Hastaların hipovolemik, septik, kardiyojenik şok oranları sırasıyla %21.9, %28.1, %50; kompanse, dekompanse, geriye dönüşsüz şok evreleri ise %21.9, %37.5, %40.6 idi. Olgularda dissemine intravasküler koagülasyon (%43.8), çoklu organ yetmezliği (%28.1), akut böbrek yetmezliği (%21.9), karaciğer yetmezliğinin (%20.5) eşlik ettiği görüldü. Geç metabolik asidoz en sık doğumsal kalp hastalıkları [büyük damarların transpozisyonu, pulmoner atrezi, koarktasyon, kesintili arkus, kardiyomiyopati, atriyo-ventriküler kanal defekti; (%31.3)], sepsis (%28.1), akut böbrek yetmezliği (%18.8), doğuştan metabolizma hastalıkları [propiyonik asidemi, metil-malonik asidemi, sitrulinemi, galaktozemi, leprechaunism (%18.8)] nedenleriyle gelişmişti. NaHCO3 defisiti verildikten sonra serum pH, HCO3 ve baz fazlalığının düzeldiği saptandı (p<0.05). Mortalite oranı %28.1 idi; mekanik ventilasyon, konjenital kalp hastalığı, sepsis, doğumsal anomaliler, başvurudaki pH-pO2-pCO2- potasyum-kalsiyum-ürikasit-PT-INR düzeyleri, anyon açığı, NTISS skoruyla mortalite ilişkisi anlamlıydı (p<0.05). Kaybedilen 9 yenidoğanın NTISS skorları daha yüksekti (p=0.001).Sonuç: Yenidoğanlarda akut geç metabolik asidoz ciddi hastalıklar nedeniyle oluşmakta ve mortalitesi yüksek olabilmektedir. NaHCO3 defisit tedavisinin, diğer destek tedavilerle birlikte uygulanması asidozun düzelmesine katkı sağlamaktadır.

Anahtar Kelimeler:

Metabolik asidoz, yenidoğan, sodyum bikarbonat

ETIOLOGY OF METABOLIC ACIDOSIS IN PREVIOUSLY HEALTHY NEONATES AND ITS PROGNOSIS

Background: Late neonatal metabolic acidosis except for metabolic asidosis secondary to perinatal asphyxia generally caused by severe diseases and results in irreversible adverse outcomes. Method: The findings of hospitalized neonates without perinatal asphyxia and with gestational age>35 weeks and clinical findings of shock were analysed retrospectively. At admission, the neonates with pH≤7.30, HCO3≤16 mmol/L, base excess≥8 mmol/L, and requirement of NaHCO3 infusion were included in the study. The etiology for metabolic asidosis, factors affecting prognosis, and the effect of NaHCO3 infusion on blood gases were investigated in this study. Results: Among 1284 newborns hospitalized in our hospital between October, 2009 and September, 2010; 32 neonates with significant metabolic acidosis and clinical findings of shock required NaHCO3 infusion. Hypovolemic, septic, and cardiogenic shock were determined in 21.9%, 28.1%, and 50% of neonates; retrospectively. The stages of shock were defined as compensated, decompensated, and irreversible shock in 21.9%, 37.5%, 40.6% of neonates; respectively. There were also accompanied disseminated intravascular coagulation (43.8%), multiple organ failure (28.1%), liver failure (20.5%), and acute renal failure (21.9%) in neonates with metabolic asidosis. The most common etiological disorders for development of late metabolic asidosis were congenital heart diseases [transposition of great arteries, pulmonary atresia, coarctation, aortic interruption, cardiomyopathy, atrio-ventricular canal defect (31.3%)], sepsis (28.1%), acute renal failure (18.8%), inborn errors of metabolism [propionic acidemia, methyl-malonic acidemia, citrullinemia, galactosemia, leprechaunism (18.8%)].After the infusion of NaHCO3; a statistically significant improvement was detected on parameters of pH, HCO3, and base excess (p<0.05). The mortality rate was 28.1% in this series. The relationship between mortality and requirement of mechanical ventilation; the diagnosis of congenital heart disease, septicemia, congenital anomalies; serum levels of pH, pO2, pCO2, K+, Ca++, uric acid, PT, INR, anion gap, NTISS was found to be statistically significant (p<0.05). Nine neonates who was lost had higher NTISS scores than the neonates who were not lost (p= 0.017). Conclusion: Late neonatal metabolic acidosis is often associated with severe diseases, and may have high mortality rates. NaHCO3 infusion together with other supportive therapies may contribute to the improvement of the asidosis

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