危重症新生儿毛细血管渗漏综合征的临床流行病学调查

发布时间：2018-05-15 06:50

本文选题：毛细血管渗漏综合征 + 流行病学　；参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景毛细血管渗漏综合征(capillary leakage syndrome,CLS)是新生儿病房危重症之一,临床表现复杂,分期界限模糊,诊断及治疗均没有统一的标准,严重者可导致心、脑、肺、肾等多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)。随着医疗水平的提高,很多危重CLS患儿有了进一步治疗的机会,但目前国际上缺乏公认的预测及诊疗标准,因而预防性治疗措施有限;尤其在治疗新生儿CLS方法的选择方面更是缺乏大规模的临床研究,多种诊疗措施的使用仍存在争议。研究目的CLS的诊疗需要一个综合管理方案,影响疗效的因素颇多。因此,探寻早期预测及治疗CLS的有效方法,通过早期干预疾病的发生发展,对减少其并发症,缩短治疗时间、减轻经济负担,提高生存率及改善预后等方面均有着极其重要的临床意义。目前国内外文献多为针对婴幼儿或成人CLS的研究,尚无关于危重新生儿发生CLS的流行病学报道。我们对2011年01月01日-2015年12月31日广州地区3家三级医院危重新生儿CLS的发病率及其影响因素、治疗及转归等方面进行临床调查,以获取危重新生儿发生CLS的流行病学资料,为CLS患儿的临床诊疗提供依据。研究方法1.研究对象:2011年01月01日-2015年12月31日广州地区3家三级医院新生儿科(南方医科大学南方医院、广州市妇女儿童医院、广州医科大学附属第三医院)收治的危重症新生儿中发生CLS患儿。2.诊断标准:危重症新生儿诊断标准参照中华医学会新生儿危重病例评分法(草案),评分90分或者符合新生儿危重病例单项指标标准的属危重病例。CLS的纳入标准:①原发病无法解释的血压、中心静脉压下降;②全身水肿,伴有胸腔或腹腔积液或心包积液;③氧合指数300mmHg;④胸片提示有间质性渗出改变;⑤血清白蛋白显著降低(25g/L),红细胞比容(HCT)降低不明显。排除标准:心源性、肾源性、肝源性水肿及遗传代谢性疾病引起的水肿。3.统计学处理:采用SPSS19.0统计软件,计量资料以均数±标准差(x±s)表示,非正态分布计量资料以[M(P25-P75)]表示,采用χ2检验,危险因素分析采用二分类logistic回归分析,P0.05为差异有统计学意义。结果1.发病率及病死率:2011年01月01日-2015年12月31日广州地区3家三级医院新生儿科共收治危重症新生儿3029例,发生CLS49例,发病率1.62%,95%的CI为1.17%～2.07%;其中死亡15例,病死率为30.6%,95%的CI为17.71%～43.51%。2.CLS患儿基本情况:49例CLS患儿中,男36例(73.5%),女13例(26.5%),男女发病率差异无统计学意义(1.88%vs 1.16%,P=0.129);胎龄(26～41+4)周,平均(32.8±4.5)周;体重(750～3740)g,平均(1890±840)g;剖宫产 24 例(48.9%),多胎12例(24.5%),早产低体重儿34例(69.4%),试管婴儿2例(4.1%);母亲有高危因素20例(40.8%),产前宫内感染12例(24.5%),出生窒息史17例(34.7%),先天异常19例(38.8%,其中心脏疾病14例,胃肠道畸形2例,先天性甲状腺功能减退1例,先天性膈疝1例,葡萄糖-6-磷酸脱氢酶缺乏1例)、高血糖6例(12.2%)、硬肿症2例(4.1%)。血培养阳性8例(16.3%),诊断脓毒症11例(22.4%)。多因素logistic回归分析显示危重症患儿发生CLS的危险因素主要为母亲高危、休克、急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)、先天性心脏病等。.3.CLS治疗:使用呼吸机辅助通气45例(91.8%),持续时间中位数为12(4.5-25.5)d;使用抗生素44例(89.7%),持续时间中位数为14(7.5-28.5)d;使用糖皮质激素24例(51.0%,主要使用小剂量地塞米松或氢化可的松),持续时间中位数为3(3.0-9.5)d,其中使用激素3d的患儿占44%,≤3d占60%,≤15d占96%;使用血管活性药物39例(79.6%),血制品30例(61.2%),白蛋白29例(59.2%),人工胶体20例(40.8%),肺表面活性物质15例(30.6%),手术治疗9例(18.3%),此外还包括利尿剂、静脉营养支持、镇静剂及对症处理等。4.病情转归:治疗好转34例(69.4%),死亡-15例(30.6%);水肿发生时间的中位数为入院的第2(2-3)d,其中入院24小时内发病4例(8.2%),48小时内发病29例(59.2%),72小时内发病41例(83.7%),水肿持续时间的中位数为7(3-10)d。住院时间的中位数为21(8.5-51)d,其中好转出院患儿住院时间中位数为34(16.7-59.5)d,死亡患儿住院时间的中位数为4(2-17)d,P0.001。多因素logistic回归分析显示影响CLS患儿转归的主要因素为MODS。结论1.CLS是新生儿病房的危重症之一,病死率高,预后不佳,需要通过早期预测、早期干预以提高CLS患儿的生存率和改善预后。2.危重症患儿发生CLS的危险因素主要为母亲高危、休克、ARDS、先天性心脏病等;.3.CLS患儿的的水肿多发生在入院72小时内,持续1周左右;4.CLS患儿住院时间长,死亡多发生在住院早期,影响转归的主要因素为MODS。
[Abstract]:Capillary leakage syndrome (CLS) is one of the critical diseases in neonatal ward. The clinical manifestations are complex, the stages are blurred, and the diagnosis and treatment are not unified. The serious patients can lead to the multiple organ dysfunction syndrome (multiple organ dysfunction syndrome, MODS), such as the heart, the brain, the lung and the kidney. With the improvement of medical level, many critical CLS children have a chance of further treatment. However, there is a lack of recognized standard of prediction and diagnosis and treatment in the world. Therefore, the preventive treatment measures are limited, especially in the treatment of CLS methods for newborns, the lack of large-scale clinical research, and the dispute of the use of various diagnosis and treatment measures. Objective the diagnosis and treatment of CLS needs a comprehensive management scheme, and there are many factors affecting the curative effect. Therefore, to explore the effective methods of early prediction and treatment of CLS, through the early intervention of the occurrence and development of the disease, it is extremely important to reduce its complications, shorten the time of treatment, reduce the economic burden, improve the survival rate and improve the prognosis. At present, most of the literature at home and abroad is aimed at the study of infant or adult CLS, and there is no epidemiological report on the occurrence of CLS in critically ill neonates. We conducted a clinical investigation on the incidence of CLS in critically ill neonates in 3 grade three hospitals in Guangzhou area, 2011, -2015, and its influencing factors, treatment and prognosis. The epidemiological data of CLS in critically ill neonates were taken to provide basis for the clinical diagnosis and treatment of children with CLS. Research methods 1. subjects were studied in 3 newborn children of three grade hospitals in Guangzhou region, 01 months, 2011, December 31st -2015 years (Southern Medical University South Hospital, Guangzhou women's and children's Hospital, and Third Affiliated Hospital of Guangzhou Medical University). .2. diagnostic criteria for children with CLS in critically ill neonates: the criteria for critical neonatal diagnosis refer to the critical case scoring method of the Chinese Medical Association (Draft). The score of 90 points or the criteria for critical cases of neonatal critical cases is a standard for critical cases of critical cases: (1) the inexplicable blood pressure and the decrease of central venous pressure; (2) systemic edema, accompanied by pleural or peritoneal effusion or pericardial effusion; (3) oxygenation index 300mmHg; (4) chest radiograph showed interstitial exudation; serum albumin decreased significantly (25g/L), and erythrocyte specific volume (HCT) was not significantly reduced. Exclusion criteria: cardiogenic, renal origin, hepatogenic edema and hereditary metabolic diseases caused by.3. statistics of edema Reason: using SPSS19.0 statistical software, the measurement data were expressed with mean number + standard deviation (x + s), non normal distribution measurement data were expressed in [M (P25-P75)), using the chi 2 test, the analysis of risk factors adopted two classification logistic regression analysis, P0.05 was statistically significant. Results 1. incidence and fatality rate: 01 months 2011 -2015 year December 31st Guangzhou A total of 3029 newborn children in 3 grade three hospitals in the region were admitted to 3029 cases of critically ill neonates. The incidence of CLS49 was 1.62%, and 95% of CI was 1.17% to 2.07%. 15 of them died, the mortality rate was 30.6%, and 95% of CI was from 17.71% to 43.51%.2.CLS in children: 49 cases of CLS, male 36 cases (73.5%) and female cases, there was no statistical difference between men and women. Meaning (1.88%vs 1.16%, P=0.129), gestational age (26 to 41+4) weeks, average (32.8 + 4.5) weeks, weight (750~3740) g, average (1890 + 840) g, 24 cases of caesarean section (48.9%), 12 cases of multiple births (24.5%), 34 cases of premature birth and low weight infants (69.4%), infants in vitro, antenatal intrauterine infection, birth asphyxia history, 19 cases of congenital abnormalities (38.8%, including 14 cases of heart disease, 2 cases of gastrointestinal malformation, 1 congenital hypothyroidism, 1 congenital diaphragmatic hernia, 1 cases of glucose -6- phosphate dehydrogenase deficiency), 6 cases of hyperglycemia (12.2%), 2 cases of sclerosis, 2 cases (16.3%) and diagnostic sepsis in 2 cases (16.3%). Multiple factor Logistic regression analysis showed critical weight. The main risk factors for CLS in children were mother high risk, shock, acute respiratory distress syndrome (acute respiratory distress syndrome, ARDS), congenital heart disease,..3.CLS treatment, 45 cases (91.8%) with ventilator ventilation, median duration of 12 (4.5-25.5) d, 44 cases of antibiotics (89.7%), median duration of 14 (7.5-28.5) d; 24 cases of Glucocorticoid (51%, mainly using small dose of dexamethasone or hydrocortisone), the median duration was 3 (3.0-9.5) d, of which 44%, 60%, and 96%, with hormone 3D, 39 (79.6%), 30 blood products (61.2%), 29 (59.2%) albumin (59.2%), 20 cases of artificial colloid. There were 15 cases (30.6%) of pulmonary surfactant and 9 cases (18.3%) with surgical treatment, including diuretics, venous nutrition support, sedative and symptomatic treatment, such as.4., 34 cases (69.4%), death -15 (30.6%), and second (2-3) d of the admission time, among which 4 cases (8.2%) were onset within 24 hours and 48 hours within 24 hours. In 29 cases (59.2%) and 41 cases (83.7%) within 72 hours, the median of the duration of edema was 7 (3-10) d., and the median of hospitalization time was 21 (8.5-51) d, of which the median of hospitalization time was 34 (16.7-59.5) d, and the median of hospitalized time of the children was 4 (2-17) d, P0.001. multiple factor Logistic regression analysis showed that the children affected CLS to turn. The main factor of return is MODS. conclusion that 1.CLS is one of the critical diseases in neonatal ward, with high mortality and poor prognosis. Early intervention is needed to improve the survival rate of CLS children and improve the prognosis of CLS in children with.2. critical disease mainly for mother high risk, shock, ARDS, congenital heart disease, and so on; children with.3.CLS Edema occurred mostly within 72 hours of admission and lasted for about 1 weeks. 4.CLS hospitalization time was long, and death occurred mostly in the early stage of hospitalization. The main factor affecting the outcome was MODS..

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R722.1

【参考文献】