极低出生体重儿肠外营养相关性胆汁淤积的临床高危因素

Clinical high-risk factors of parenteral nutrition-associated cholestasis in very low birth weight infants

目的探讨极低出生体重儿肠外营养相关性胆汁淤积（PNAC）的临床特点及高危因素，为该病的防治提供依据。方法选取2013年1月至2014年10月青岛大学附属医院新生儿科收治的胎龄≤34周、接受肠外营养（PN）支持〉14d的141例极低出生体重儿，按是否发生PNAC分为PNAC组（n=32）和非PNAC组（n=109），回顾性分析并比较两组的临床资料。结果非PNAC组与PNAC组之间胎龄[（30．84±1．55）周比（29．68±2．04）周，t=2．952，P=0．005]、出生体重[（1267．92±160．39）g比（1050．63±229．74）g，t=6．064，P=0．000]、住院时间[（43．26±14．43）d比（66．47±22．25）d，t=-6．622，P=0．000]、禁食时间[（6．30±5．23）d比（11．94±7．92）d，t=-4．723，P=0．000]、PN持续时间[（32．40±13．72）d比（57．59±27．65）d，t=-7．039，P=0．000]、氨基酸最大日用量[（3．61±0．27）g／（kg·d）比（3．78±0．35）g／（kg·d），t=-3．012，P=0．003]，合并感染（56．88％比87．50％，χ2=10．046，P=0．002）、肺炎（32．11％比68．75％，χ2=13．790，P=0．000）、坏死性小肠结肠炎（0．92％比9．38％，χ2=6．420，P=0．037）、新生儿呼吸窘迫综合征（55．05％比78．13％，χ2=5．503，P=0．019）、支气管肺发育不良（19．27％比46．88％，χ2=9．918，P=0．002）、先天性心脏病（4．59％比21．88％，χ2=7．405，P=0．007），应用肺表面活性物质（33．94％比59．38％，χ2=6．682，P=0．010）、经鼻持续气道正压通气（60．55％比87．50％，χ2=8．085，P=0．004）、机械通气（22．94％比43．75％，χ2=5．356，P=0．021）、经外周静脉置入中心静脉导管（44．04％比81．25％，χ2=13．737，P=0．000）的差异均有统计学意义。多因素Logistic回归分析显示PN持续时间为PNAC的独立高危因素（B=0．069，OR=1．071，95％CI=1．039—1．104，P=0．000）。结论PNAC为多种因素共同作用所致，其中PN持续时间为其独立高危因素。尽早给予肠内喂养，缩短PN持续时间为降低PNAC发生率的保护措施。

Objective To investigate the clinical characteristics and high-risk factors of parenteral nutri- tion-associated cholestasis （PNAC） in very low birth weight infants （VLBWI）, so as to guide the prevention and treatment of this condition. Methods A retrospective analysis was conducted with the data of 141 VLBWI collected from January 2013 to October 2014 in Affiliated Hospital of Qingdao University. These VLBWI were of gestational age ≤ 34 weeks and received parenteral nutrition （PN） for 〉 14 days in Neonatal Intensive Care Unit. According to the existence of PNAC, they were divided into PNAC group （ n = 32） and non-PNAC group （ n = 109） and analyzed in terms of clinical features. Results Between the non-PNAC and the PNAC groups, univariate analysis showed significant differences in gestational age [ （30. 84 ± 1.55 ） weeks vs. （29. 68 ±2. 04） weeks, t=2.952, P=0.005], birth weight [ （1 267.92±160.39） gvs. （1 050. 63 ±229. 74） g, t=6.064, P=0.0001, hospital stay [（43.26±14.43） d vs. （66.47 ±22.25） d, t = -6.622, P= 0.000], fasting time[ （6.30±5.23） dvs. （11.94±7.92） d, t= -4.723, P=0.000], PN duration （ 32.40 ± 13. 72 ） d vs. （57. 59 ± 27. 65 ） d, t = - 7. 039, P = 0. 000 ], the maximum daily dosage of amino acid [ （3.61 ±0.27） g/ （kg.d） vs. （3.78±0.35） g/ （kg.d）, t= -3.012, P=0.003]; concurrent infection （56.88% vs. 87.50%, χ2 = 10.046, P =0.002）, pneumonia （32.11% vs. 68.75%, χ2 = 13. 790, P =0. 000）, necrotizing enterocolitis （0. 92% vs. 9.38% ,χ2 =6. 420, P =0. 037）, neonatal respir- atory distress syndrome （55.05% vs. 78. 13% , χ2 = 5. 503, P = 0. 019 ） , bronehopulmonary dysplasia （19.27% vs. 46.88%, χ2 =9.918, P =0.002）, congenital heart disease （4.59% vs. 21.88%, χ2= 7. 405, P =0. 007） ; application of pulmonary surfactant （33.94% vs. 59. 38%, χ2 = 6. 682, P = 0. 010）, continuous positive airway pressure ventilation （60. 55% vs. 87.50% , χ2 = 8. 085, P = 0. 004） , mechanical ventilation （ 22.94% vs. 43.75% , χ2 = 5. 356, P = 0. 021 ） and peripherally inserted central catheter （44.04% vs. 81.25 % , χ2 = 13. 737, P = 0. 000 ）. Multivariate Logistic regression analysis revealed that PN duration was an independent high-risk factor of PNAC （B = 0. 069, OR = 1. 071, 95% CI = 1. 039 - 1. 104, P = 0. 000）. Conclusions Many factors are associated with PNAC, in which PN duration is an independent high-risk factor. Early enteral nutrition and shortened duration of PN may be protective measures for PNAC.