出生体重<1500 g早产儿静脉营养疗效及并发症观察

Observation on the efficacy and complications of intravenous nutrition strategy in premature infants with birth weight<1500g

目的结合文献探讨针对出生体重<1500 g早产儿静脉营养方案的安全性及有效性。方法回顾性分析2012年10月至2018年12月山东省聊城市人民医院新生儿ICU收治的93例出生体重<1500 g的极低或超低出生体重儿的临床资料。所有早产儿在积极治疗原发病、早期肠内营养的基础上,均采用"全合一"静脉营养方案加强营养支持,配方包括6%小儿复方氨基酸、20%脂肪乳、葡萄糖、维生素、NaCl、KCl、微量元素及矿物质,静脉营养液在20~24 h匀速输入。观察静脉营养干预前后早产儿生长发育指标和生化指标的变化,记录静脉营养相关性胆汁淤积症(PNAC)等静脉营养并发症的发生情况及预后。绘制受试者工作特征曲线(ROC),评估各项指标对宫外生长发育迟缓(EUGR)的预测能力。结果93例早产儿均纳入分析,胎龄(28.75±1.93)周,出生体重(1113.28±190.48)g。93例早产儿中,除4例死亡外,其余89例均达到出院标准,总住院时间(51.64±15.98)d。89例存活早产儿最大体重下降百分比(4.42±3.12)%,恢复出生体重所需时间(6.36±2.60)d;日平均体重增长速率(19.53±4.64)g/kg,周平均身长增长(1.06±0.34)cm,周平均头围增长(0.69±0.22)cm。89例存活患儿静脉营养持续时间(21.56±8.54)d,出院时体重、身长、头围均较入重症医学科(ICU)时明显增加〔体重(g):2191.63±186.00比1118.71±188.78,身长(cm):45.21±1.50比37.34±2.56,头围(cm):31.04±1.27比25.96±1.80〕,白蛋白(Alb)水平明显升高(g/L:27.52±3.77比25.70±3.88),尿素氮(BUN)水平明显降低(mmol/L:1.65±1.39比5.11±3.20),差异均有统计学意义(均P<0.05)。89例存活早产儿中有79例(88.8%)存在早产儿贫血,48例(53.9%)达到输血标准;42例(47.2%)存在糖代谢紊乱,38例(42.7%)存在电解质紊乱,9例(10.1%)存在PNAC;出院时38例早产儿(42.7%)存在体重评价的EUGR。ROC曲线分析显示,极低或超低出生体重儿胎龄、出生体重及恢复出生体重所需时间三者联合对EUGR有较好的预测价值,ROC曲线下面积(AUC)为0.902,敏感度为86.4%,特异度为86.8%。结论针对出生体重<1500 g早产儿的静脉营养方案安全、有效;但静脉营养可引起糖代谢和电解质紊乱以及PNAC等并发症,需注意监测;尽早EN,缩短静脉营养持续时间是预防PNAC的重要措施;胎龄、出生体重及恢复出生体重所需时间三者联合对EUGR有较好的预测价值,可以在住院早期加强干预,避免EUGR的发生。

Objective To explore the safety and efficacy of intravenous nutrition strategy for preterm infants with birth weight<1500 g combined with literatures.Methods The clinical data of 93 preterm infants with very low or extremely low birth weight(<1500 g)who were admitted to the neonatal intensive care unit(NICU)of Liaocheng People's Hospital of Shandong Province from October 2012 to December 2018 were retrospectively analyzed.On the basis of active treatment of primary disease and early enteral nutrition,all preterm infants received"all-in-one"intravenous nutrition strategy.The intravenous nutrient solution containing 6%pediatric compound amino acids,20%fat emulsion,glucose,vitamins,NaCl,KCl,microelements and minerals was transfused uniformly in 20-24 hours.The changes in growth and biochemical indexes of preterm infants before and after intravenous nutrition intervention were observed.The occurrence of intravenous nutritional complications such as parenteral nutrition associated cholestasis(PNAC)and prognosis were recorded.The receiver operating characteristic(ROC)curve was plotted to assess the predictive power of each indicator for extra uterine growth retardation(EUGR).Results Ninety-three preterm infants were enrolled in the final analysis.The gestational age was(28.75±1.93)weeks and the birth weight was(1113.28±190.48)g.All the children except 4 non-surviving preterm infants were discharged from hospital.The average hospitalization time was(51.64±15.98)days.In 89 surviving preterm infants,the maximum weight loss percentage was(4.42±3.12)%,and the time to regain birth weight was(6.36±2.60)days.In these surviving preterm infants,the daily average growth rate of weight gain was(19.53±4.64)g/kg,and the weekly average growth of body length and head circumference gain was(1.06±0.34)cm and(0.69±0.22)cm,respectively.The mean duration of intravenous nutrition was(21.56±8.54)days in 89 surviving preterm infants.The body weight,body length and head circumference of these surviving preterm infants were increased significantly at discharge compared with their admission to NICU[body weight(g):2191.63±186.00 vs.1118.71±188.78,body length(cm):45.21±1.50 vs.37.34±2.56,head circumference(cm):31.04±1.27 vs.25.96±1.80].The level of albumin(Alb)was significantly increased(g/L:27.52±3.77 vs.25.70±3.88),however the blood urea nitrogen(BUN)level was significantly reduced(mmol/L:1.65±1.39 vs.5.11±3.20)with statistical differences(all P<0.05).In the 89 surviving preterm infants,79 preterm infants(88.8%)suffered from premature anemia and 48(53.9%)achieved transfusion criteria.Forty-two preterm infants(47.2%)had glucose metabolism disorder and 38(42.7%)had electrolyte disturbances.PNAC occurred in 9 preterm infants(10.1%).Thirty-eight preterm infants(42.7%)had EUGR in weight.ROC curve analysis showed that the combination of gestational age,birth weight and time to restore birth weight had a good predictive value for EUGR in very low or extremely low birth weight preterm infants,and the area under the ROC curve(AUC)was 0.902,the sensitivity was 86.4%,and the specificity was 86.8%.Conclusions The intravenous nutrition strategy for preterm infants with birth weight<1500 g is effective and safe.However,intravenous nutrition can cause some complications,such as glucose metabolism disorder,electrolyte disturbances and PNAC,etc.So the process of intravenous nutrition should be closely monitored.To start EN as early as possible and shorten the duration of intravenous nutrition is an important measure for the prevention of PNAC.The combination of gestational age,birth weight and the time to regain birth weight has a good predictive value for EUGR,and intervention can be strengthened early in hospital to avoid EUGR.