极早产儿坏死性小肠结肠炎预后影响因素分析

Influencing factors on prognosis of necrotizing enterocolitis in premature infants： a retrospective study

目的 探讨影响出生胎龄28～32周的极早产儿坏死性小肠结肠炎（neonatalnecrotizing enterocolitis,NEC）预后的因素. 方法 本研究为回顾性研究.研究对象为2009年1月1日至2013年1月1日北京军区总医院附属八一儿童医院收治的胎龄28～32周、Bell分期≥Ⅱ期的NEC患儿46例.根据预后分为治愈组（29例）和预后不良组（17例）.统计2组患儿的一般情况、围产期情况、实验室检查结果、治疗措施、并发症以及预后等.采用x2检验（或Fisher精确概率法）和单因素方差分析进行统计学处理. 结果 2组性别比例、出生体重和发病日龄和围产期情况差异均无统计学意义（P值均＞0.05）.2组外周血白细胞计数升高/降低和血小板计数减少的比例差异无统计学意义.NEC发病前或发病初期进行的血培养检测发现,预后不良组NEC患儿中血培养阳性者6例,而治愈组无血培养阳性者.2组发病前1周接受输血[治愈组和预后不良组分别为41.4％（12/29）和11/17]和口服布洛芬[治愈组和预后不良组分别为6.9％（2/29）和5/17]等治疗的情况差异无统计学意义（P值均＞0.05）,但治愈组使用肠道微生态制剂的比例为69.0％（20/29）,多于预后不良组的5/17,差异有统计学意义（x2=6.758,P=0.009）.治愈组29例中,14例接受手术治疗;预后不良组17例中,10例接受手术治疗,且术后均死亡.治愈组接受2次及以上手术治疗者1例（占3.4％）,少于预后不良组（6/17）,差异有统计学意义（Fisher精确概率法,P=0.007）.治愈组接受粒细胞集落刺激因子治疗者多于预后不良组[分别为51.7％ （15/29）与3/17,x2=5.225,P=0.022].治愈组与预后不良组相比,败血症[44.8％（13/29）与15/17,x2=8.478]、动脉导管未闭[17.2％（5/29）与9/17,x2=6.451;P值均＜0.05]、消化道穿孔[3.4％（1/29）与6/17]、多系统器官衰竭[0.0％ （0/29）与5/17]、弥散性血管内凝血[0.0％（0/29）与3/17]和感染性休克[3.4％（1/29）与6/17]的发生率差异均有统计学意义（P值均＜0.05）. 结论 发病前服用肠道微生物制剂、起病后使用粒细胞集落刺激因子可能是改善极早产NEC患儿预后的保护性因素,而合并动脉导管未闭、败血症、消化道穿孔、多系统器官衰竭、弥散性血管内凝血、感染性休克是影响预后的危险因素.

Objective To determine the influencing factors on prognosis of neonatal necrotizing enterocolitis （NEC） in premature infants with a gestational age of 28-32 weeks.Methods Forty-six cases of NEC （Bell stage Ⅱ or Ⅲ） with a gestational age of 28-32 weeks admitted to Bayi Children＇s Hospital from January,2009 to January,2013 were analyzed retrospectively.Twenty-nine cases were assigned to the cured group and 17 cases were assigned to the poor prognosis group according to prognosis.General conditions,laboratory results,treatment and complications in the two groups were analyzed.The Chi-square test,Fisher＇s exact test and univariate analysis of variance were used for statistical analysis.Results There were no statistically significant differences regarding gender,average birth weight and mean age of onset between the two groups [average birth weight （1 410.52±281.59） g vs （1 266.47±280.32） g and mean age of onset：（20.79± 10.61） d vs （16.71 ±9.41） d for the cured group versus the poor prognosis group,respectively].There were no difference in changes in white blood cells and platelets between the two groups.There were six cases of positive blood culture in the poor prognosis group and none in the cured group.There were no differences in procedures such as blood transfusion and ibuprofen administration [41.4% （12/29） vs 11/17 and 6.9% （2/29） vs 5/17,both P〉0.05,in the cured group versus the poor prognosis group,respectively].There were significant differences in the use of Bifidobacterium between the two groups [69.0% （20/29） vs 5/17,x2=6.758,P=0.009].Fourteen cases in the cured group and 10 cases in the poor prognosis group underwent surgery,and all 10 cases in the poor prognosis group died.Seven cases underwent repeated surgery,one infant in the cured group and six infants in the poor prognosis group and a significant difference was observed （Fisher＇s exact,P=0.007）.A statistically significant difference in granulocyte colony-stimulating factor （G-CSF） treatment was observed between the two groups,where 15 cases in the cured group and three cases in the poor prognosis group were treated with G-CSF （x2=5.225,P〈0.05）.Statistically significant differences in septicemia,patent ductus arteriosus,gastrointestinal perforation,multiple organ failure （MOF）,disseminated intravascular coagulopathy （DIC） and septic shock were observed between the two groups [septicemia：44.8% （13/29） vs 15/17,x2=8.478; patent ductus arteriosus：17.2% （5/29） vs 9/17,x2=6.451; gastrointestinal perforation：3.4% （1/29） vs 6/17; MOF：0.0% （0/29） vs 5/17; DIC：0.0% （0/29） vs 3/17; septic shock：3.4% （1/29） vs 6/17,all P〈0.05 in the cured group versus the poor prognosis group,respectively）.Conclusions Oral intestinal microbial preparations before the onset of NEC and G-CSF therapy after the onset of NEC may be protective factors in improving the prognosis of NEC,while patent ductus arteriosus,septicemia,gastrointestinal perforation,MOF,DIC and septic shock are risk factors.Emphasis should be placed on the administration of intestinal microbial agents,prevention of infection and treatment of complications.