超未成熟儿的临床救治情况

Clinical treatment in extremely preterm infants

目的研究超未成熟儿(extremelypremature infant,EPI)的救治存活情况、并发症发生率及影响临床转归的危险因素。方法采用回顾性分析方法对2008年1月1日至2017年12月31日在广州医科大学附属第三医院新生儿科出院的311例EPI的临床资料进行分析,按不同出生胎龄、体重、出院年份分组比较其存活率、死亡率及并发症发生率,采用多因素非条件Logistic回归分析影响EPI存活率的危险因素。结果纳入研究的311例EPI中,平均胎龄(26.6±1.0)周,平均体重(923±180)g,存活117例(37.6%),救治无效死亡38例(12.2%),因各种原因放弃治疗后死亡156例(50.2%)。2013年至2017年与2008年至2012年比较,EPI在出生胎龄<26周、26~26+6周、27~27+6周及出生体重<750 g、750~999 g、≥1 000 g的构成比及总体存活率比较差异均无统计学意义(P>0.05);但EPI的救治无效死亡率、放弃治疗相关的死亡率、矫正存活率比较差异均有统计学意义(P<0.001)。出生胎龄<26周、26~26+6周、27~27+6周的存活率分别为17.6%(12/68)、32.6%(30/92)、49.7%(75/151),组间比较差异有统计学意义(χ2趋势值=21.885,P<0.001);出生体重<750 g、750~999 g、≥1 000 g组的存活率分别16.7%(8/48)、35.8%(58/162)、50.5%(51/101),组间比较差异有统计学意义(χ2趋势值=16.342,P<0.001)。EPI的前五位并发症发生率依次为新生儿呼吸窘迫综合征[92.0%(286/311)]、支气管肺发育不良[81.3%(100/123)]、早产儿视网膜病变[59.5%(78/131)]、院内感染[49.5%(107/216)]、脑室周围-脑室内出血[44.1%(71/161)]。多因素非条件Logistic回归分析显示,出生胎龄<27周(<26周,OR=3.122,95%CI 1.443~6.752,P=0.004;26~26+6周,OR=1.834,95%CI 1.035~3.250,P=0.038),出生体重<750 g(OR=2.769,95%CI 1.078~7.109,P=0.034)、窒息(OR=2.566,95%CI 1.241~5.302,P=0.011)、肺出血(OR=2.188,95%CI 1.155~4.145,P=0.016)是影响EPI存活的独立危险因素;产前使用糖皮质激素(OR=0.449,95%CI 0.244~0.827,P=0.010)是影响EPI存活的保护性因素。结论在国内,EPI的救治存活率仍较低,放弃救治率高;随胎龄的增加,救治存活率增高;影响EPI救治存活的独立危险因素是出生胎龄<27周、出生体重<750 g、窒息、肺出血,保护因素为产前使用糖皮质激素。

Objective To study the survival rate,incidence of complications and the risk factors affecting clinical outcomes for extremely preterm infants(EPI).Methods The clinical data of 311 cases of EPI discharged from department of neonatology,the Third Affiliated Hospital of Guangzhou Medical University from January 1,2008 to December 31,2017 were analyzed by retrospective analysis.The survival rate,mortality rate and incidence of complications were compared according to gestational age(GA),birth weight(BW)and the year of discharge.Multivariate unconditional Logistic regression analysis was used to analyze the risk factors affecting EPI survival rate.Results In the 311 EPI,the average GA was(26.6±1.0)weeks and average BW was(923±180)g,117(37.6%)infants survived,38(12.2%)infants died of treatment failure,and 156(50.2%)infants died after giving up treatment for various reasons.There were no significant differences in composition ratio or overall survival rate for EPI(GA=26 weeks,26-26+6 weeks,27-27+6 weeks or BW<750 g,750-999 g,≥1000 g)between 2013-2017 and 2008-2012(P>0.05).However,there were significant differences in mortality of treatment failure,mortality of abandon treatment,and corrected survival rate(P<0.001).The survival rates of GA<26 weeks,26-26+6 weeks,27-27+6 weeks were 17.6%(12/68),32.6%(30/92),and 49.7%(75/151),respectively.There were statistical significant differences among these groups(χ2=21.885,P<0.001).Similarly,the survival rates of BW<750 g,750-999 g,and≥1000 g groups were 16.7%(8/48),35.8%(58/162),and 50.5%(51/101),respectively.There were statistical differences among these groups(χ2=16.342,P<0.001).The incidence of the top five complications in EPI was 92.0%(286/311)for neonatal respiratory distress syndrome,81.3%(100/123)for bronchopulmonary dysplasia,59.5%(78/131)for retinopathy of prematurity,49.5%(107/216)for nosocomial infection,44.1%(71/161)for periventricular-intraventricular hemorrhage.Multivariate unconditional Logistic regression analysis showed that the independent risk factors affecting EPI survival were GA<27 weeks(GA<26weeks,OR=3.122,95%CI 1.443-6.752,P=0.004;26-26+6 weeks,OR=1.834,95%CI 1.035-3.250,P=0.038),BW<750 g(OR=2.769,95%CI 1.078-7.109,P=0.034),asphyxia(OR=2.566,95%CI 1.241-5.302,P=0.011)and pulmonary hemorrhage(OR=2.188,95%CI 1.155-4.145,P=0.016),while the protective factor was antenatal corticosteroids(OR=0.449,95%CI 0.244-0.827,P=0.010).Conclusions In China,the survival rate of EPI is still low while the rate of abandoning treatment is high,and the survival rate increase with the increase of gestational age.The independent risk factors affecting the survival of EPI treatment are GA<27 weeks,BW<750 g,asphyxia and pulmonary hemorrhage.The protective factor is antenatal corticosteroids.