早产儿广泛坏死型坏死性小肠结肠炎的临床特点及相关因素分析

Clinical characteristics and risk factors of extensive necrotizing enterocolitis in preterm infants

目的分析早产儿广泛坏死型坏死性小肠结肠炎(necrotizing enterocolitis totalis,NEC-T)的临床特点及发生全肠坏死的相关因素。方法回顾性分析中国医科大学附属盛京医院2011年1月至2020年12月收治的42例于手术中证实的NEC-T早产儿临床资料,设为NEC-T组;收集同期收治的644例非广泛坏死型坏死性小肠结肠炎(no-necrotizing enterocolitis totalis,NEC-nonT)早产儿临床资料,设为NEC-nonT组,其中362例采取手术治疗,为NEC-nonT手术组。总结NEC-T组早产儿临床特点,并与NEC-nonT手术组患儿比较,分析手术患儿发生全肠坏死的相关因素。结果42例NEC-T患儿占同时期NEC收治总人数的6.1%(42/686)。与NEC-nonT组相比,NEC-T组患儿出生体质量较低[(1501±740)g比1709±1102)g],窒息发生率较高[76.2%(32/42)比25%(161/644)],发病年龄较小[(7.8±7.6)d比(14.6±13.4)d],发病至手术的时间较短[(6.6±6.5)d比(30.4±24.4)d],BellⅢ期患儿所占比率较高[85.7%(36/42)比62.7%(404/644)],发病后休克的发生率较高[76.2%(32/42)比36.6%(236/644)],死亡率较高[100%(42/42)比6.6%(32/644)],差异均有统计学意义(P<0.001)。因NEC需术中判定是否存在全肠坏死,遂将NEC-T组与NEC-nonT手术组进行比较,分析NEC全肠坏死相关因素,结果显示,NEC-T组急性期严重肠壁下积气[52.4%(22/42)比21.0%(76/362)]、低血压[69.0%(29/42)比40.3%(146/362)]、气腹[66.7%(28/42)比40.3%(176/362)]、低钠血症[85.7%(36/42)比51.4%(186/362)]、腹壁红斑[88.1%(37/42)比18.2%(66/362)]及血小板减少症[85.7%(36/42)比15.5%(56/362)]的人数比例均明显高于NEC-nonT手术组,差异有统计学意义(P<0.001)。Logistic回归分析结果显示,腹壁红斑、严重肠壁下积气、低钠血症、血小板减少症是NEC-T的独立相关因素(P<0.05)。手术患儿NEC-T评分达到3分时,预测NEC-T的敏感性为92%、特异性为68%;达到5分时,预测NEC-T的敏感性为54%,特异性为98%。结论NEC-T早产儿临床症状重,病情进展快,死亡率高。对于存在NEC-T相关因素的新生儿,需要密切观察,科学分析,尽早干预,以降低NEC的发生率和病死率。

Objective To explore the clinical characteristics of extensive necrotizing enterocolitis(NEC-T)in preterm infants and the related factors of total intestinal necrosis.Methods From January 2011 to December 2020,clinical data were reviewed retrospectively for 42 NEC-T preterm infants(NEC-T group).And,during the same period,no necrotizing enterocolitis totalis(NEC-nonT)preterm infants(NEC-nonT group,including operation and non-operation sub-groups)were compared.The related factors of total intestinal necrosis were analyzed compared with NEC-nonT.Results Forty-two NEC-T children accounted for 6.1%(42/686)of the total number of NEC during the same period.Compared with NEC-nonT counterparts,NEC-T preterm infants had a lower birth weight[(1501±740)vs.(1709±1102)grams]and a higher asphyxia rate[76.2%(32/42)vs.25%(161/644)].The differences were statistically significant.Compared with NEC-nonT group,age of onset was younger[(7.8±7.6)vs.(14.6±13.4)days],time interval between onset and operation was shorter[(6.6±6.5)vs.(30.4±24.4)days],higher ratio of Bell phaseⅢ[85.7%(36/42)vs.62.7%(404/644)],greater rate of post-onset shock[76.2%(32/42)vs.36.6%(236/644)]and higher mortality rate[100%(42/42)vs.5.0%(32/644)].The differences were statistically significant.Analysis of related factors of intestinal necrosis:severe subwall pneumatosis in two groups in acute stage[52.4%(22/42)vs.21.0%(76/362)],hypotension[69.0%(29/42)vs.40.3%(146/362)],pneumoperitoneum[66.7%(28/42)vs.40.3%(176/362)],hyponatremia[85.7%(36/42)vs.51.4%(186/362)],abdominal erythema[88.1%(37/42)vs.18.2%(66/362)]and thrombocytopenia[85.7%(36/42)vs.15.5%(56/362)].NEC-T group was significantly higher than NEC-nonT group and the difference was statistically significant;Logistic multiple stepwise regression analysis indicated that abdominal erythema,severe subwall pneumatosis,hyponatremia and thrombocytopenia were independent risk factors for NEC-T(P<0.05).NEC-T score:3 had 92%sensitivity and 68%specificity to NEC-T while the sensitivity of 5 decreased by 54%and the specificity was significantly higher than 98%.Conclusion NEC-T premature infants have severe clinical symptoms,rapid disease progression and a high mortality.Newnates with NEC-T risk factors require close observations,reasonable analysis,early prevention and intervention to reduce the incidence and mortality of NEC.