本文選題：毛細(xì)血管滲漏綜合征 + 流行病學(xué)�。� 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景毛細(xì)血管滲漏綜合征(capillary leakage syndrome,CLS)是新生兒病房危重癥之一,臨床表現(xiàn)復(fù)雜,分期界限模糊,診斷及治療均沒(méi)有統(tǒng)一的標(biāo)準(zhǔn),嚴(yán)重者可導(dǎo)致心、腦、肺、腎等多器官功能障礙綜合征(multiple organ dysfunction syndrome,MODS)。隨著醫(yī)療水平的提高,很多危重CLS患兒有了進(jìn)一步治療的機(jī)會(huì),但目前國(guó)際上缺乏公認(rèn)的預(yù)測(cè)及診療標(biāo)準(zhǔn),因而預(yù)防性治療措施有限;尤其在治療新生兒CLS方法的選擇方面更是缺乏大規(guī)模的臨床研究,多種診療措施的使用仍存在爭(zhēng)議。研究目的CLS的診療需要一個(gè)綜合管理方案,影響療效的因素頗多。因此,探尋早期預(yù)測(cè)及治療CLS的有效方法,通過(guò)早期干預(yù)疾病的發(fā)生發(fā)展,對(duì)減少其并發(fā)癥,縮短治療時(shí)間、減輕經(jīng)濟(jì)負(fù)擔(dān),提高生存率及改善預(yù)后等方面均有著極其重要的臨床意義。目前國(guó)內(nèi)外文獻(xiàn)多為針對(duì)嬰幼兒或成人CLS的研究,尚無(wú)關(guān)于危重新生兒發(fā)生CLS的流行病學(xué)報(bào)道。我們對(duì)2011年01月01日-2015年12月31日廣州地區(qū)3家三級(jí)醫(yī)院危重新生兒CLS的發(fā)病率及其影響因素、治療及轉(zhuǎn)歸等方面進(jìn)行臨床調(diào)查,以獲取危重新生兒發(fā)生CLS的流行病學(xué)資料,為CLS患兒的臨床診療提供依據(jù)。研究方法1.研究對(duì)象:2011年01月01日-2015年12月31日廣州地區(qū)3家三級(jí)醫(yī)院新生兒科(南方醫(yī)科大學(xué)南方醫(yī)院、廣州市婦女兒童醫(yī)院、廣州醫(yī)科大學(xué)附屬第三醫(yī)院)收治的危重癥新生兒中發(fā)生CLS患兒。2.診斷標(biāo)準(zhǔn):危重癥新生兒診斷標(biāo)準(zhǔn)參照中華醫(yī)學(xué)會(huì)新生兒危重病例評(píng)分法(草案),評(píng)分90分或者符合新生兒危重病例單項(xiàng)指標(biāo)標(biāo)準(zhǔn)的屬危重病例。CLS的納入標(biāo)準(zhǔn):①原發(fā)病無(wú)法解釋的血壓、中心靜脈壓下降;②全身水腫,伴有胸腔或腹腔積液或心包積液;③氧合指數(shù)300mmHg;④胸片提示有間質(zhì)性滲出改變;⑤血清白蛋白顯著降低(25g/L),紅細(xì)胞比容(HCT)降低不明顯。排除標(biāo)準(zhǔn):心源性、腎源性、肝源性水腫及遺傳代謝性疾病引起的水腫。3.統(tǒng)計(jì)學(xué)處理:采用SPSS19.0統(tǒng)計(jì)軟件,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,非正態(tài)分布計(jì)量資料以[M(P25-P75)]表示,采用χ2檢驗(yàn),危險(xiǎn)因素分析采用二分類logistic回歸分析,P0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果1.發(fā)病率及病死率:2011年01月01日-2015年12月31日廣州地區(qū)3家三級(jí)醫(yī)院新生兒科共收治危重癥新生兒3029例,發(fā)生CLS49例,發(fā)病率1.62%,95%的CI為1.17%～2.07%;其中死亡15例,病死率為30.6%,95%的CI為17.71%～43.51%。2.CLS患兒基本情況:49例CLS患兒中,男36例(73.5%),女13例(26.5%),男女發(fā)病率差異無(wú)統(tǒng)計(jì)學(xué)意義(1.88%vs 1.16%,P=0.129);胎齡(26～41+4)周,平均(32.8±4.5)周;體重(750～3740)g,平均(1890±840)g;剖宮產(chǎn) 24 例(48.9%),多胎12例(24.5%),早產(chǎn)低體重兒34例(69.4%),試管嬰兒2例(4.1%);母親有高危因素20例(40.8%),產(chǎn)前宮內(nèi)感染12例(24.5%),出生窒息史17例(34.7%),先天異常19例(38.8%,其中心臟疾病14例,胃腸道畸形2例,先天性甲狀腺功能減退1例,先天性膈疝1例,葡萄糖-6-磷酸脫氫酶缺乏1例)、高血糖6例(12.2%)、硬腫癥2例(4.1%)。血培養(yǎng)陽(yáng)性8例(16.3%),診斷膿毒癥11例(22.4%)。多因素logistic回歸分析顯示危重癥患兒發(fā)生CLS的危險(xiǎn)因素主要為母親高危、休克、急性呼吸窘迫綜合征(acute respiratory distress syndrome,ARDS)、先天性心臟病等。.3.CLS治療:使用呼吸機(jī)輔助通氣45例(91.8%),持續(xù)時(shí)間中位數(shù)為12(4.5-25.5)d;使用抗生素44例(89.7%),持續(xù)時(shí)間中位數(shù)為14(7.5-28.5)d;使用糖皮質(zhì)激素24例(51.0%,主要使用小劑量地塞米松或氫化可的松),持續(xù)時(shí)間中位數(shù)為3(3.0-9.5)d,其中使用激素3d的患兒占44%,≤3d占60%,≤15d占96%;使用血管活性藥物39例(79.6%),血制品30例(61.2%),白蛋白29例(59.2%),人工膠體20例(40.8%),肺表面活性物質(zhì)15例(30.6%),手術(shù)治療9例(18.3%),此外還包括利尿劑、靜脈營(yíng)養(yǎng)支持、鎮(zhèn)靜劑及對(duì)癥處理等。4.病情轉(zhuǎn)歸:治療好轉(zhuǎn)34例(69.4%),死亡-15例(30.6%);水腫發(fā)生時(shí)間的中位數(shù)為入院的第2(2-3)d,其中入院24小時(shí)內(nèi)發(fā)病4例(8.2%),48小時(shí)內(nèi)發(fā)病29例(59.2%),72小時(shí)內(nèi)發(fā)病41例(83.7%),水腫持續(xù)時(shí)間的中位數(shù)為7(3-10)d。住院時(shí)間的中位數(shù)為21(8.5-51)d,其中好轉(zhuǎn)出院患兒住院時(shí)間中位數(shù)為34(16.7-59.5)d,死亡患兒住院時(shí)間的中位數(shù)為4(2-17)d,P0.001。多因素logistic回歸分析顯示影響CLS患兒轉(zhuǎn)歸的主要因素為MODS。結(jié)論1.CLS是新生兒病房的危重癥之一,病死率高,預(yù)后不佳,需要通過(guò)早期預(yù)測(cè)、早期干預(yù)以提高CLS患兒的生存率和改善預(yù)后。2.危重癥患兒發(fā)生CLS的危險(xiǎn)因素主要為母親高危、休克、ARDS、先天性心臟病等;.3.CLS患兒的的水腫多發(fā)生在入院72小時(shí)內(nèi),持續(xù)1周左右;4.CLS患兒住院時(shí)間長(zhǎng),死亡多發(fā)生在住院早期,影響轉(zhuǎn)歸的主要因素為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..

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R722.1

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