新生儿窒息多器官损害发生率、高危因素和转归的多中心研究

Incidence, risk factors and outcomes of multiple organ damage after neonatal asphyxia

目的探讨新生儿窒息多器官损害的发生率、高危因素和转归，为加强复苏后管理，降低新生儿窒息的病死率和伤残率提供客观指标和临床依据。方法选择2012年11月至2015年2月课题组协作医院收治的足月及胎龄大于34周，且出生体重大于2 500 g的窒息新生儿487例，根据Apgar评分诊断新生儿窒息及其程度，并分为窒息合并严重代谢性酸中毒（pH≤7和/或碱剩余≤－16 mmol/L）和非严重代谢性酸中毒亚组（7〈pH≤7.2，碱剩余〉－16 mmol/L但〈－8 mmol/L）。采用t检验、秩和检验及χ2检验比较轻度窒息和重度窒息、窒息是否合并严重代谢性酸中毒组间多器官损害发生情况、危险因素及转归。结果（1）487例窒息患儿中轻度窒息371例，重度窒息116例；47.6%（232/487）发生窒息多器官损害。重度窒息组多器官损害发生率高于轻度窒息组[79.3%（92/116）与37.7%（140/371），χ^2=59.58，P〈0.01]。（2）高危因素：窒息多器官损害组急诊剖宫产率高于窒息无多器官损害组[14.7%（34/232）与5.9%（15/255）]，但规律产前检查比例较低[57.8%（134/232）与89.8%（229/255]；P值均〈0.01。（3）重度窒息严重代谢性酸中毒组多器官损害发生率高于重度窒息非严重代谢性酸中毒组[90.7%（39/43）与73.0%（27/37），χ^2=11.36，P〈0.01]。（4）窒息多器官损害组平均住院时间长于窒息无多器官损害组[11（8～15）与8（6～9）d]，治愈好转率较低[92.2%（214/232）与98.0%（250/255）]，病死率较高[4.3%（10/232）与0（0/255）]；重度窒息严重代谢性酸中毒组治愈好转率低于重度窒息非严重代谢性酸中毒组[79.1%（34/43）与86.5%（32/37）]，病死率高于重度窒息非严重代谢性酸中毒组[20.9%（9/43）与2.7%（1/37）]；P值均〈0.01。结论新生儿窒息会导致脑、心、肺、肝、胃肠等多器官不同程度损害，尤其是重度窒息，且合并严重代谢性酸中毒时更严重。

Objective To investigate the incidence, risk factors and outcomes of multiple organ damage （MOD） after neonatal asphyxia and formulate the diagnostic criteria of MOD, in order to strengthen the management of neonatal asphyxia and provide evidences for reduction of the mortality and disability rate of asphyxia newborns. Methods Totally, 487 asphyxiated newborns, who were term neonates or preterm neonates with fetal age over 34 weeks and birth weight over 2 500 g and admitted to hospitals included in the collaboration group from November 2012 to February 2015 were selected. Neonatal asphyxia was diagnosed based on Apgar score, and all recruited newborns were divided into mild and severe groups, and those in severe group were devided into two subgroups （Group Ⅰ and group Ⅱ ）. Group I included those babies with severe asphyxia and serious metabolic acidosis （pH ≤ 7 and/or base excess ≤ - 16 mmol/L） and group 11 were those without serious metabolism acidosis group （7〈pH ≤ 7.2, - 16 〈 base excess 〈 - 8 mmol/L）. Two sample t, Chi-square and Sum-rank tests were used as statistical methods. Results （1） Among the 487 cases of neonatal asphyxia, 371 were mild asphyxia and 116 were severe ones. Altogether, 232 out of the 487 babies （47.6%） developed multiple organ injury of asphyxia. More MOD babies were seen in the severe asphyxia group than in the mild asphyxia group [79.3% （92/116） vs 37.7% （140/371）, χ^2=59.58, P〈0.01]. （2） Babies with MOD after asphyxia were more likely to be born by emergency cesarean delivery [14.7% （34/232） vs 5.9% （15/255）], but less likely to have regular prenatal care [57.8% （134/232） vs 89.8% （229/255）] 0（2=9.04 and 65.73, all P〈0.01）. （3） Incidence of MOD in group 1 was significantly higher than that in group Ⅱ [90.7% （39/43） vs 73.0% （27/37）,χ^2=11,36, P〈0.01]; （4） The median hospital stay of MOD newborns was longer than that of non-MOD ones [ 11 （8-15） vs 8 （6-9） d, P〈0.01], the recovery rate was lower [92.2% （214/232） vs 98.0% （250/255）, P〈0.01], and the mortality rate was higher [4.3% （10/232） vs 0（0/255）, P〈0.01]. The recovery rate in group I was lower than that of group Ⅱ [79.1% （34/43） vs 86.5% （32/37）, P〈0.01], and the mortality rate was higher [20.9% （9/43） vs 2.7% （1/37）, P〈0.01]. Conclusion Neonatal asphyxia might lead to MOD including brain, heart, lungs, liver and gastrointestinal system, especially when babies were severe asphyxiated and complicated with serious metabolic acidosis.