危重新生儿协作网的建立及重庆市危重新生儿诊治现状的多中心调查

发布时间：2018-06-03 23:46

本文选题：危重新生儿 + 存活率　；参考：《重庆医科大学》2016年博士论文

【摘要】：目的:医学模式由经验医学模式向循证医学模式转变后,循证医学的发展需要大量的多中心研究提供高质量的临床证据。在新生儿学多中心研究的发展过程中,协作网模式在发达国家逐渐建立起来,并成为迅速发展的临床群体研究的主要模式,持续地作为评价NICU质量的工具。目前国内这方面的工作尚处于起步阶段,本研究旨在建立危重新生儿协作网,并以此为平台调查重庆地区危重新生儿的诊治现状,为提高危重新生儿的诊疗水平提供帮助。方法:本研究为基于危重新生儿协作网的多中心临床流行病学研究。使用ASP.NET开发平台建立数据库,确立数据库的病例纳入条件:1.出生体重1500g或孕周32周的早产儿;2.确诊或临床诊断的败血症;3.新生儿坏死性小肠结肠炎(neonatal necrotizing enterocolitis,NEC);4.机械通气时间≥4小时。满足4项纳入条件中的一项即为病例进入数据库的标准。统计2013年1月至2015年12月间重庆地区22家协作单位提交资料的一般信息、疾病发生率、存活率、诊治措施,分析统计结果与2014年加拿大新生儿协作网(Canadian Neonatal Network,CNN)年度报表在危重新生儿诊治方面存在的差距和差别。结果:数据库建立后通过预测于2013年顺利上线运行。研究期间数据库共收集临床病例3505例,其中出生体重小于1500g或孕周32周的1028例(占29.3%),确诊或临床诊断的败血症1673例(47.7%),坏死性小肠结肠炎620例(17.7%),机械通气≥4小时1650例(47.1%)。平均住院天数14(7.0,23.0)天,总体治愈率为53.4%。(1)出生体重1500g或孕周32周的小早产儿:平均孕周30.1±4.3周,平均出生体重1436.2±379.0g,其中出生体重1000g的超低出生体重儿i50例(4.9%),出生孕周28周的超未成熟儿54例(5.3%)。各孕周存活率及出生体重存活率与cnn比较差距较大。产前使用地塞米松406例(39.5%),其中足量使用191例(18.6%)。829例(80.6%)完善头颅b超检查,首次检查在3天之内完成的有555例(54.0%),315例(34.0%)发现有颅内出血,其中248例(29.9%)为i-ii级,67例(8.1%)为iii-iv级,低于2014年cnn报告。诊断新生儿呼吸窘迫综合征共528例(51.4%),414例(78.4%)使用肺表面活性物质,211例(40.0%)使用insure技术,273例(51.7%)使用经鼻持续正压通气(nasalcontinuouspositiveairwaypressure,ncpap)。经典型支气管肺发育不良(bronchopulmonaydysplasia,bpd)发生率为16.4%,新型bpd发生率13.7%,稍低于2014年cnn报告。动脉导管未闭(patentductusarterious,pda)发生率为58.9%,干预比率为4.7%,明显低于cnn报告的55.6%。早产儿视网膜病变(retinopathyofprematurity,rop)筛查385例(37.5%),有i-ii期rop95例(24.7%),iii期以上4例(1.0%),给予干预的10例(10.1%),筛查率及干预率均低于cnn报告。有nec116例(11.3%),其中ii-iii级30例(2.9%),干预4例(13.3%),低于cnn报告的32.2%。(2)确诊或临床诊断的败血症:早发败血症感染以g-为主,主要为大肠埃希菌及克雷伯菌。晚发败血症感染以g+为主,主要为凝固酶阴性葡萄球菌。晚发败血症更好发于早产儿,而早发败血症合并呼吸衰竭的比率更高,两者死亡率无统计学差异。抗生素使用的前3位的分别为青霉素(包括半合成青霉素,66.9%),3~4代头孢菌素(47.9%)及碳青霉烯类(28.2%),其中碳青霉烯类平时使用时间为10.8±9.2天。使用静注丙种球蛋白组与未使用组在合并nec发生率及死亡率上无统计学差异(p0.05)。(3)坏死性小肠结肠炎:孕周32周,32周~及≥37周三组间ii-iii级nec发生率,外科手术比率及死亡无统计学差异(p0.05)。确诊nec的足月儿无腹胀表现稍高于早产儿。孕周越小,腹部x线特征性表现的比率越高,但组间比较无统计学差异(χ2=3.282,p=0.194)。(4)机械通气≥4小时:机械通气并发症根据发生率从高到低分别为:呼吸机相关性肺炎(1.2%),气漏综合征(1.0%),肺不张(0.3%)及bpd(0.1%)。有创通气较ncpap的机械通气并发症发生率明显下降。ncpap病例病情危重程度较有创通气低,死亡率也较低。机械通气初始吸氧浓度越高,其初始有创通气比率越高,死亡率越高。结论:建立危重新生儿协作网,并以此为平台开展多中心研究是可行的。重庆地区小早产儿的存活率与cnn相比有较大差距。重庆地区收治的小早产儿中,elbwi及epi的比例比较低.在3天内行头颅b超检查、ncpap支持、加强rop筛查和干预、内外科医师协同诊治NEC方面需要进一步加强。同时需要增加nCPAP在新生儿机械通气治疗中使用以减少机械通气并发症,并改善预后。
[Abstract]:Objective: after the transformation of the medical model from the empirical model to the evidence-based medicine model, the development of evidence-based medicine needs a large number of multicenter studies to provide high quality clinical evidence. In the process of the development of the multicentre research on newborn science, the cooperative network model is gradually established in the developed countries and has become the master of the rapid development of the clinical group. In order to evaluate the status of critical newborns in Chongqing and to improve the diagnosis and treatment level of critically ill newborns in Chongqing, this study aims to improve the diagnosis and treatment level of critically ill newborns. A multicenter clinical epidemiology study of the newborns cooperation network, using the ASP.NET development platform to establish a database to establish the conditions for the database cases: 1. birth weight 1500g or 32 weeks of pregnancy; 2. diagnosed or clinically diagnosed septicemia; 3. neonatal necrotizing enterocolitis (neonatal necrotizing enterocolitis, NEC); 4. machinery. The duration of ventilation is more than 4 hours. One of the 4 inclusion conditions is the standard of the case entering the database. The general information, the incidence of disease, the survival rate, the diagnosis and treatment measures, the statistical results and the Canadian newborns cooperation network (Canadian Neonatal) in 2014 (Canadian Neonatal) Network, CNN) the differences and differences in the diagnosis and treatment of critically ill neonates. Results: after the establishment of the database, the database was run smoothly in 2013. 3505 cases of clinical cases were collected during the study, including 1028 cases of birth weight less than 1500g or 32 weeks of pregnancy (29.3%), and 1673 cases of diagnosed or clinically diagnosed sepsis. (47.7%) 620 cases of necrotizing enterocolitis (17.7%) and 1650 cases (47.1%) with mechanical ventilation over 4 hours (47.1%). The average hospitalization day was 14 (7.0,23.0) days. The total cure rate was 53.4%. (1) birth weight 1500g or the small preterm infants of 32 weeks pregnant week: average gestational age 30.1 + 4.3 weeks, average birth weight 1436.2 + 379.0g, and the ultra-low birth weight infant of birth weight 1000g was i50 For example (4.9%) 54 cases (5.3%) of super immature infants born at 28 weeks of birth. The survival rate and the survival rate of birth weight were larger than that of CNN. 406 cases (39.5%) were used for prenatal use of dexamethasone, of which 191 cases (18.6%).829 cases (80.6%) improved the head B Ultrasound examination, for the first time, 555 cases (54%) were completed within 3 days, 315 cases (34%) were first examined. Existing intracranial hemorrhage, of which 248 (29.9%) was I-II, 67 (8.1%) was III-IV, lower than the 2014 CNN report. 528 cases (51.4%) were diagnosed with neonatal respiratory distress syndrome, 414 cases (78.4%) used pulmonary surfactant, 211 (40%) used insure technique, 273 (51.7%) used nasal continuous positive pressure ventilation (nasalcontinuouspositiveairwaypres). Sure, nCPAP). The incidence of classic bronchopulmonary dysplasia (bronchopulmonaydysplasia, BPD) was 16.4%, the incidence of new BPD was 13.7%, slightly lower than the 2014 CNN report. The incidence of patent ductus arteriosus (patentductusarterious, PDA) was 58.9%, the intervention ratio was 4.7%, and 55.6%. premature infant retinopathy (retinopathyofprema) was significantly lower than CNN reported (retinopathyofprema) Turity, ROP) were screened in 385 cases (37.5%), rop95 cases (24.7%), 4 cases (1%) above III and 10 cases (10.1%). The screening rate and intervention rate were lower than CNN reports. There were nec116 cases (11.3%), including II-III class 30 cases (2.9%), 4 cases (13.3%), 32.2%. (2) diagnosed or clinically diagnosed sepsis below CNN report: premature sepsis infection with G The main is Escherichia coli and Klebsiella. Late septicemia infection is mainly g+, mainly coagulase negative Staphylococcus. Late septicemia is better in premature infants, while the rate of premature septicemia with respiratory failure is higher, the mortality rate is not statistically different. Penicillin (including penicillin) in the top 3 antivegetative use (including half of penicillin) Synthetic penicillin, 66.9%), 3~4 generation cephalosporin (47.9%) and carbapenems (28.2%), of which carbapenems were used for 10.8 + 9.2 days. There was no significant difference in the incidence and mortality of NEC (3) necrotizing enterocolitis (3) necrotizing enterocolitis (32 weeks, 32 weeks ~ 37 Wednesday group). There was no statistical difference in the rate of II-III NEC between the surgical operation ratio and death (P0.05). The no abdominal distention in the full-term infants of the confirmed NEC was slightly higher than that of the premature infants. The lower the pregnancy week, the higher the ratio of the X-ray characteristic expression to the abdomen, but there was no statistical difference between the groups (x 2=3.282, p=0.194). (4) the mechanical ventilation was more than 4 hours: the complications of mechanical ventilation were based on the occurrence of mechanical ventilation. The rate from high to low were ventilator associated pneumonia (1.2%), gas leak syndrome (1%), pulmonary atelectasis (0.3%) and BPD (0.1%). The incidence of mechanical ventilation complications was significantly lower than that of nCPAP. The severity of.Ncpap was lower and the mortality was lower. The higher the initial oxygen concentration of mechanical ventilation, the initial invasive ventilation The higher the ratio, the higher the mortality rate. Conclusion: it is feasible to establish a multi center research on the critical newborns cooperation network and on this platform. The survival rate of small preterm infants in Chongqing has a large gap compared with CNN. In the small preterm infants in Chongqing area, the proportion of ELBWI and EPI is low. In 3 days, the head B Ultrasound examination, nCPAP support, and the strengthening of R OP screening and intervention, internal and external physicians need to be further strengthened in conjunction with the diagnosis and treatment of NEC. At the same time, it is necessary to increase the use of nCPAP in neonatal mechanical ventilation to reduce mechanical ventilation complications and improve the prognosis.
【学位授予单位】：重庆医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R720.597

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