出生胎龄<34周住院早产儿出院预后分析

Outcomes at discharge of preterm infants born<34 weeks′gestation

目的:分析出生胎龄<34周住院早产儿出院预后及其3年变化趋势。方法:应用“基于证据的质量改进方法降低我国新生儿重症监护室院内感染发生率的整群随机对照试验”所建立的早产儿前瞻性队列数据库的研究数据进行二次分析。纳入25家三级新生儿重症监护病房(NICU)2015年5月至2018年4月在出生7 d内入院的27 192例出生胎龄<34周早产儿,并排除严重先天畸形者。根据出生胎龄和入院时间分组,计算不同出生胎龄住院早产儿出院时病死率和主要并发症发生率。采用Cochran-Armitage检验和Jonckheere-Terpstra检验分析3年间早产儿病死率和并发症发生率的变化趋势;构建多因素Logistic回归模型分析3年间早产儿出院预后的差异。结果:27 192例早产儿出生胎龄(31.3±2.0)周,出生体重(1 617±415)g。自动出院率9.5%(2 594/27 192),总病死率10.7%(2 907/27 192),完整治疗患儿病死率为4.7%(1 147/24 598),完整治疗患儿死亡或主要并发症发生率为26.2%(6 452/24 598)。主要并发症发生率由高至低分别为中重度支气管肺发育不良16.0%(4 342/27 192)、败血症11.9%(3 225/27 192)、重度脑室内出血或脑室周围白质软化6.8%(1 641/24 206)、确诊坏死性小肠结肠炎3.6%(939/25 762)、严重早产儿视网膜病1.5%(214/13 868)。研究期间3年总病死率下降( P<0.001),败血症、严重早产儿视网膜病发生率也均呈下降趋势(均 P<0.001)。完整治疗存活早产儿主要并发症发生率3年差异无统计学意义( P=0.230)。校正混淆因素后,研究第3年总死亡风险显著低于第1年(调整 OR=0.62,95% CI 0.55~0.69, P<0.001),完整治疗患儿死亡或主要并发症、中重度支气管肺发育不良、败血症和严重早产儿视网膜病发生风险也均低(均 P<0.05)。 结论:2015—2018年NICU住院早产儿病死率及主要并发症发生率呈现降低趋势,但死亡或主要并发症发生率仍有较大的下降空间,需持续开展针对性质量改进,进一步提高救治质量、改善早产儿预后。

Objective To investigate the incidence and trend of short-term outcomes among preterm infants born<34 weeks′gestation.Methods A secondary analysis of data from the standardized database established by a multicenter cluster-randomized controlled study"reduction of infection in neonatal intensive care units(NICU)using the evidence-based practice for improving quality(REIN-EPIQ)study".This study was conducted in 25 tertiary NICU.A total of 27192 infants with gestational age<34 weeks at birth and admitted to NICU within the first 7 days of life from May 2015 to April 2018 were enrolled.Infants with severe congenital malformation were excluded.Descriptive analyses were used to describe the mortality and major morbidities of preterm infants by gestational age groups and different admission year groups.Cochran-Armitage test and Jonckheere-Terpstra test were used to analyze the trend of incidences of mortality and morbidities in 3 study-years.Multiple Logistic regression model was constructed to analyze the differences of outcomes in 3 study-years adjusting for confounders.Results A total of 27192 preterm infants were enrolled with gestational age of(31.3±2.0)weeks at birth and weight of(1617±415)g at birth.Overall,9.5%(2594/27192)of infants were discharged against medical advice,and the overall mortality rate was 10.7%(2907/27192).Mortality for infants who received complete care was 4.7%(1147/24598),and mortality or any major morbidity was 26.2%(6452/24598).The incidences of moderate to severe bronchopulmonary dysplasia,sepsis,severe intraventricular hemorrhage or periventricular leukomalacia,proven necrotizing enterocolitis,and severe retinopathy of prematurity were 16.0%(4342/27192),11.9%(3225/27192),6.8%(1641/24206),3.6%(939/25762)and 1.5%(214/13868),respectively.There was a decreasing of the overall mortality(P<0.001)during the 3 years.Also,the incidences for sepsis and severe retinopathy of prematurity both decreased(both P<0.001).However,there were no significant differences in the major morbidity in preterm infants who received complete care during the 3-year study period(P=0.230).After adjusting for confounders,infants admitted during the third study year showed significantly lower risk of overall mortality(adjust OR=0.62,95%CI 0.55-0.69,P<0.001),mortality or major morbidity,moderate to severe bronchopulmonary dysplasia,sepsis and severe retinopathy of prematurity,compared to those admitted in the first study year(all P<0.05).Conclusions From 2015 to 2018,the mortality and major morbidities among preterm infants in Chinese NICU decreased,but there is still space for further efforts.Further targeted quality improvement is needed to improve the overall outcome of preterm infants.