發(fā)布時間：2018-06-03 23:46

  本文選題：危重新生兒 + 存活率��； 參考：《重慶醫(yī)科大學(xué)》2016年博士論文

【摘要】：目的:醫(yī)學(xué)模式由經(jīng)驗醫(yī)學(xué)模式向循證醫(yī)學(xué)模式轉(zhuǎn)變后,循證醫(yī)學(xué)的發(fā)展需要大量的多中心研究提供高質(zhì)量的臨床證據(jù)。在新生兒學(xué)多中心研究的發(fā)展過程中,協(xié)作網(wǎng)模式在發(fā)達國家逐漸建立起來,并成為迅速發(fā)展的臨床群體研究的主要模式,持續(xù)地作為評價NICU質(zhì)量的工具。目前國內(nèi)這方面的工作尚處于起步階段,本研究旨在建立危重新生兒協(xié)作網(wǎng),并以此為平臺調(diào)查重慶地區(qū)危重新生兒的診治現(xiàn)狀,為提高危重新生兒的診療水平提供幫助。方法:本研究為基于危重新生兒協(xié)作網(wǎng)的多中心臨床流行病學(xué)研究。使用ASP.NET開發(fā)平臺建立數(shù)據(jù)庫,確立數(shù)據(jù)庫的病例納入條件:1.出生體重1500g或孕周32周的早產(chǎn)兒;2.確診或臨床診斷的敗血癥;3.新生兒壞死性小腸結(jié)腸炎(neonatal necrotizing enterocolitis,NEC);4.機械通氣時間≥4小時。滿足4項納入條件中的一項即為病例進入數(shù)據(jù)庫的標(biāo)準(zhǔn)。統(tǒng)計2013年1月至2015年12月間重慶地區(qū)22家協(xié)作單位提交資料的一般信息、疾病發(fā)生率、存活率、診治措施,分析統(tǒng)計結(jié)果與2014年加拿大新生兒協(xié)作網(wǎng)(Canadian Neonatal Network,CNN)年度報表在危重新生兒診治方面存在的差距和差別。結(jié)果:數(shù)據(jù)庫建立后通過預(yù)測于2013年順利上線運行。研究期間數(shù)據(jù)庫共收集臨床病例3505例,其中出生體重小于1500g或孕周32周的1028例(占29.3%),確診或臨床診斷的敗血癥1673例(47.7%),壞死性小腸結(jié)腸炎620例(17.7%),機械通氣≥4小時1650例(47.1%)。平均住院天數(shù)14(7.0,23.0)天,總體治愈率為53.4%。(1)出生體重1500g或孕周32周的小早產(chǎn)兒:平均孕周30.1±4.3周,平均出生體重1436.2±379.0g,其中出生體重1000g的超低出生體重兒i50例(4.9%),出生孕周28周的超未成熟兒54例(5.3%)。各孕周存活率及出生體重存活率與cnn比較差距較大。產(chǎn)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%)完善頭顱b超檢查,首次檢查在3天之內(nèi)完成的有555例(54.0%),315例(34.0%)發(fā)現(xiàn)有顱內(nèi)出血,其中248例(29.9%)為i-ii級,67例(8.1%)為iii-iv級,低于2014年cnn報告。診斷新生兒呼吸窘迫綜合征共528例(51.4%),414例(78.4%)使用肺表面活性物質(zhì),211例(40.0%)使用insure技術(shù),273例(51.7%)使用經(jīng)鼻持續(xù)正壓通氣(nasalcontinuouspositiveairwaypressure,ncpap)。經(jīng)典型支氣管肺發(fā)育不良(bronchopulmonaydysplasia,bpd)發(fā)生率為16.4%,新型bpd發(fā)生率13.7%,稍低于2014年cnn報告。動脈導(dǎo)管未閉(patentductusarterious,pda)發(fā)生率為58.9%,干預(yù)比率為4.7%,明顯低于cnn報告的55.6%。早產(chǎn)兒視網(wǎng)膜病變(retinopathyofprematurity,rop)篩查385例(37.5%),有i-ii期rop95例(24.7%),iii期以上4例(1.0%),給予干預(yù)的10例(10.1%),篩查率及干預(yù)率均低于cnn報告。有nec116例(11.3%),其中ii-iii級30例(2.9%),干預(yù)4例(13.3%),低于cnn報告的32.2%。(2)確診或臨床診斷的敗血癥:早發(fā)敗血癥感染以g-為主,主要為大腸埃希菌及克雷伯菌。晚發(fā)敗血癥感染以g+為主,主要為凝固酶陰性葡萄球菌。晚發(fā)敗血癥更好發(fā)于早產(chǎn)兒,而早發(fā)敗血癥合并呼吸衰竭的比率更高,兩者死亡率無統(tǒng)計學(xué)差異�？股厥褂玫那�3位的分別為青霉素(包括半合成青霉素,66.9%),3~4代頭孢菌素(47.9%)及碳青霉烯類(28.2%),其中碳青霉烯類平時使用時間為10.8±9.2天。使用靜注丙種球蛋白組與未使用組在合并nec發(fā)生率及死亡率上無統(tǒng)計學(xué)差異(p0.05)。(3)壞死性小腸結(jié)腸炎:孕周32周,32周~及≥37周三組間ii-iii級nec發(fā)生率,外科手術(shù)比率及死亡無統(tǒng)計學(xué)差異(p0.05)。確診nec的足月兒無腹脹表現(xiàn)稍高于早產(chǎn)兒。孕周越小,腹部x線特征性表現(xiàn)的比率越高,但組間比較無統(tǒng)計學(xué)差異(χ2=3.282,p=0.194)。(4)機械通氣≥4小時:機械通氣并發(fā)癥根據(jù)發(fā)生率從高到低分別為:呼吸機相關(guān)性肺炎(1.2%),氣漏綜合征(1.0%),肺不張(0.3%)及bpd(0.1%)。有創(chuàng)通氣較ncpap的機械通氣并發(fā)癥發(fā)生率明顯下降。ncpap病例病情危重程度較有創(chuàng)通氣低,死亡率也較低。機械通氣初始吸氧濃度越高,其初始有創(chuàng)通氣比率越高,死亡率越高。結(jié)論:建立危重新生兒協(xié)作網(wǎng),并以此為平臺開展多中心研究是可行的。重慶地區(qū)小早產(chǎn)兒的存活率與cnn相比有較大差距。重慶地區(qū)收治的小早產(chǎn)兒中,elbwi及epi的比例比較低.在3天內(nèi)行頭顱b超檢查、ncpap支持、加強rop篩查和干預(yù)、內(nèi)外科醫(yī)師協(xié)同診治NEC方面需要進一步加強。同時需要增加nCPAP在新生兒機械通氣治療中使用以減少機械通氣并發(fā)癥,并改善預(yù)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.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R720.597

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