新生儿先天性膈疝术后呼吸支持相关危险因素分析

Risk factors of postoperative respiratory support in newborns with congenital diaphragmatic hernia

目的探讨先天性膈疝(CDH)新生儿手术后呼吸支持情况,以及影响术后呼吸支持时间的相关危险因素。方法选择2015年1月至2023年6月浙江大学医学院附属儿童医院胸外科收治的接受手术治疗,并早期存活的96例CDH新生儿为研究对象。采取回顾性分析方法,对96例CDH新生儿临床资料,如出生体重、性别、出生胎龄,生后1及5 min Apgar评分,是否合并心脏畸形、肺动脉高压,以及术前呼吸支持情况、膈肌缺损等级、疝孔位置、有无疝囊、手术径路、术后机械通气治疗时间及术后无创吸氧治疗时间,采用Mann-Whitney U检验或Kruskal-Wallis H秩和检验进行单因素分析。结合既往研究结果与临床经验及单因素分析有统计学意义指标,进一步采用多因素非条件logistic回归,分析影响CDH患儿术后有创机械通气治疗时间及无创吸氧治疗时间延长的独立影响因素。本研究遵循的程序经本院伦理委员会批准(审批文号:2022-IRB-277),所有CDH新生儿监护人对本诊断过程知情同意,并签署临床研究知情同意书。结果本研究结果如下。①这96例CDH新生儿中,男性患儿为49例,女性为47例;低出生体重儿为11例,出生体重为(2.18±0.26)kg;早产儿为8例,足月儿为88例;生后1、5 min Apgar评分为低等级者分别为5例和7例;合并肺动脉高压为47例;术前采取高频振荡通气(HFOV)或体外膜肺氧合(ECMO)治疗者为9例;膈肌缺损等级为A、B、C、D级者分别为29、38、27、2例;CDH位于左侧为78例,右侧为18例;有疝囊为45例;经胸手术为88例,经腹手术为8例。②术后有创机械通气治疗中位时间为45.0 h(23.0 h,89.8 h),术后无创吸氧治疗中位时间为7.0 d(3.0 d,9.8 d)。③多因素非条件logistic回归分析结果显示,术前合并肺动脉高压、膈肌缺损等级高(C级+D级),是导致CDH新生儿术后有创机械通气治疗时间延长的独立危险因素(OR=3.516、4.253,95%CI:1.329~9.308、1.085~16.674,P=0.011、0.038),而有疝囊是其独立保护因素(OR=0.209,95%CI:0.062~0.701,P=0.011);合并肺动脉高压、膈肌缺损等级高是导致CDH新生儿术后无创吸氧治疗时间延长的独立危险因素(OR=3.138、3.607,95%CI:1.187~8.294、1.011~12.876,P=0.021、0.048)。结论合并肺动脉高压、膈肌缺损等级高、无疝囊与CDH新生儿术后呼吸支持时间延长有关。

Objective To explore the postoperative respiratory support of neonatal congenital diaphragmatic hernia(CDH)and the risk factors affecting the time of postoperative respiratory support.Methods A total of 96 newborns with CDH who received surgical treatment in the Department of Thoracic Surgery of Children′s Hospital,Zhejiang University School of Medicine from January 2015 to June 2023 were collected.Clinical data of 96 CDH newborns such as birth weight,gender,gestational age,1 and 5 min Apgar score,cardiac malformation,pulmonary hypertension,preoperative respiratory support,diaphragma defect grade,hernia location,hernia sac,surgical approach,postoperative ventilation time and postoperative non-invasive oxygen inhalation time were analyzed by Mann-Whitney U test or Kruskal-Wallis H rank sum test.Combined with the previous research results,clinical experience,and indexes with statistical difference in univariate analysis,multivariate unconditioned logistic regression was used to analyze the independent influencing factors of postoperative ventilation time and non-invasive oxygen inhalation time.The procedure in this study was approved by the Ethics Committee of our hospital(Approval No.2022-IRB-277).Informed consents were obtained from all guardians of all participants.Results The results of this study were as follows.①Among the 96 children with CDH,there were 49 males and 47 females;11 low birth weight infants,their birth weight was(2.18±0.26)kg;8 premature infants and 88 full-term infants.The abnormal Apgar scores at 1 and 5 min after birth were 5 cases and 7 cases respectively.There were 47 children with pulmonary hypertension and 9 children with high frequency oscillation ventilation(HFOV)or extracorporeal membrane oxygenation(ECMO)before operation.With diaphragma defect grades A,B,C and D were 29,38,27 and 2 cases,respectively.78 cases of CDH were on the left side and 18 cases were on the right side,and 45 cases had hernia sac.There were 88 cases of transthoracic operation and 8 cases of transabdominal operation.②The time of postoperative ventilation was 45.0 h(23.0 h,89.8 h),and the time of postoperative non-invasive oxygen inhalation was 7.0 d(3.0 d,9.8 d).③Multivariate unconditioned logistic regression analysis showed that preoperative pulmonary hypertension,and high grade of diaphragma defect were the independent risk factors for prolonged time of postoperative ventilation(OR=3.516,4.253;95%CI:1.329-9.308,1.085-16.674;P=0.011,0.038),and with hernia sac was its independent protective factor(OR=0.209,95%CI:0.062-0.701,P=0.011).Preoperative pulmonary hypertension,and high grade of diaphragma defect also were the independent risk factors for prolonged time of non-invasive oxygen inhalation(OR=3.138,3.607;95%CI:1.187-8.294,1.011-12.876;P=0.021,0.048).Conclusions Preoperative pulmonary hypertension,high grade hernia defect and absence of hernia sac may be related to the prolongation of postoperative respiratory support time of newborns with CDH.