血流动力学监测质量改进对脓毒性休克新生儿液体超负荷及预后的影响

Impacts of quality improvement in hemodynamic monitoring on fluid overload and prognosis in neonates with septic shock

目的探讨血流动力学监测质量改进对脓毒性休克新生儿液体超负荷(fluid overload, FO)及结局的影响。方法回顾性分析广东省妇幼保健院无创心排量监测及功能性心脏超声项目实施前后收治的脓毒性休克新生儿病例资料, 2018年1月至2019年12月为改进前组, 2020年1月至2021年12月为改进后组, 改进前组常规进行液体复苏, 经验性选择血管活性药物治疗, 改进后组根据血流动力学参数指标指导液体复苏和(或)使用血管活性药物。比较两组患儿休克后24 h、48 h、72 h的FO、扩容量、有创呼吸支持时间、血管活性药物评分、休克评分及相关并发症的发生率及全因死亡率。结果共纳入284例患儿, 改进前组136例, 改进后组148例;改进后组虽然胎龄、出生体重、发病时体重均低于改进前组(P<0.05), 但48 h、72 h的FO、72 h内扩容量、肺出血和脑室周围白质软化发生率低于改进前组[48 h FO(%):29.0(-11.3, 73.7)比52.5(11.3, 79.0), 72 h FO(%):8.6(-30.9, 67.2)比38.3(-8.5, 76.1), 72 h内扩容量(ml/kg):11.3(0.0, 34.1)比39.4(12.2, 67.5), 肺出血:12.2%(18/148)比23.5%(32/136), 脑室周围白质软化:2.7%(4/148)比8.1%(11/136)], 差异均有统计学意义(P<0.05);两组24 h的FO及其他并发症发生率和全因死亡率差异均无统计学意义(P>0.05)。两组中发生脑室周围白质软化、肺出血患儿的胎龄、出生体重比较, 差异无统计学意义(P>0.05)。结论血流动力学监测质量改进可有效改善脓毒性休克新生儿FO, 降低肺出血及脑室周围白质软化发生率。

Objective To explore the effect of quality improvement of hemodynamic monitoring on fluid overload(FO)and outcome in newborns with septic shock.Methods Non-invasive cardiac output monitoring and functional cardiac ultrasound quality improvement program was started during January 2020 in our hospital.Neonates with septic shock admitted before and after the program were retrospectively analyzed.From January 2018 to December 2019 was pre-improvement period when fluid resuscitation was routinely performed and vasoactive drugs was selected empirically.From January 2020 to December 2021 was post-improvement period when fluid resuscitation and/or use and adjustment of vasoactive drugs were guided by hemodynamic parameters.The 24 h,48 h,72 h FO,duration of invasive respiratory support,vasoactive-inotropic score,septic shock score,incidences of complications and all-cause mortality were compared between the two groups.Results A total of 284 eligible cases were enrolled,including 136 cases in pre-improvement group and 148 cases in post-improvement group.Post-improvement group had significantly lower gestational age(GA),birth weight(BW)and body weight at disease onset than pre-improvement group(P<0.05).Incidences of 48 h and 72 h FO,fluid resuscitation volume within 72 h,pulmonary hemorrhage and periventricular leukomalacia(PVL)were significantly lower in the post-improvement group(P<0.05).No significant differences existed in 24 h FO,other complications and all-cause mortality between the two groups(P>0.05).No significant differences existed in GA and BW for neonates with pulmonary hemorrhage and PVL between the two groups(P>0.05).Conclusions Quality improvement of hemodynamic monitoring can effectively improve FO and reduce the incidences of pulmonary hemorrhage and PVL.