危重新生儿中心导管相关不良事件的临床分析

The clinical analysis of central catheter-related adverse events in critical neonates

目的 了解危重新生儿中心导管相关不良事件(AEs)的发生率、类型和危险因素,为临床早期干预措施提供依据。方法 回顾性分析新生儿重症监护病房(NICU)、需要中心导管的217例危重新生儿的临床资料,分析不同中心导管相关AEs发生情况,不同中心导管AEs类型、危险因素,不同中心导管异常拔管原因。结果 217例危重患儿中心导管置管324例次,其中脐动脉导管(UAC)53例次,脐静脉导管(UVC)169例次,经外周静脉置入中心静脉导管(PICC)102例次;中心导管相关AEs 81例次(25.0%),不同中心导管AEs发生率由高到低依次为UVC(34.9%)、UAC(15.1%)和PICC(13.7%)。UAC总置管时间287 d,每1000导管日AEs发生率为27.9‰。UVC总置管时间1617 d,每1000导管日AEs发生率为36.5‰。PICC总置管时间2245 d,每1000导管日AEs发生率为6.2‰。UAC-AEs类型和危险因素:UAC-AEs置管失败4例次(7.5%)、导管尖端位置异常2例次(3.8%)和血流感染(BSI)2例次(3.8%)。UAC-AEs主要发生在置管时,置管失败与导管尖端位置异常有关,每1000导管日BSI发生率为7.0‰(2/287)。UVC-AEs类型和危险因素:UVC-AEs为导管尖端位置异常52例次(30.8%),BSI 3例次(1.8%)、心包积液3例次(1.8%)和胸腔积液1例次(0.6%);心包积液和胸腔积液多发生在置管后2~3 d,考虑与置管时血管壁损伤和导管尖端高位有关,每1000导管日BSI发生率为1.9‰(3/1617)。进一步UVC-BSI高危因素分析显示,UVC-BSI患儿的胎龄和出生体重明显低于UVC非BSI患儿,导管留置时间长于UVC非BSI患儿,胎龄<30周占比及胸腔积液发生率高于UVC非BSI患儿(P<0.05)。PICC-AEs类型和危险因素:置管时AEs 4例次(3.9%),包括置管失败1例次(1.0%),导管尖端位置异常3例次(2.9%);置管期间AEs 10例次(9.8%),包括液体外渗5例次(4.9%)、导管移位2例次(2.0%),胸腔积液1例次(1.0%)、心包积液1例次(1.0%)和BSI 1例次(1.0%),每1000导管日BSI发生率为0.4‰(1/2245);导管移位是心包积液和胸腔积液的主要原因。324例次中心导管置管中,异常拔管21例次(6.5%),其中UAC 2例次(3.8%)、UVC 15例次(8.9%)和PICC 4例次(3.9%)。UVC或UAC异常拔管多发生在置管时,与导管尖端位置异常有关;置管期间的严重AEs,如BSI、心包积液和感染指标增高是UVC异常拔管的原因,而液体外渗和导管移位所致的心包积液/胸腔积液是PICC异常拔管的主要原因。结论 脐导管(UC)相关AEs发生率高,导管尖端位置异常、液体外渗、导管移位是心包积液、胸腔积液的危险因素,结合即时超声引导下导管尖端位置的评估是临床降低UC-AEs的重要措施。

Objective To understand the rate,types and risk factors of central catheter-related adverse events(AEs) in critical neonates,so as to provide basis for clinical early intervention.Methods The clinical data of 217 critically neonates in neonatal intensive care unit(NICU) who required central catheters were retrospectively analyzed.The occurrence of AEs related to different central catheters,AEs types and risk factors of different central catheters,and the causes of abnormal extubation of different central catheters were analyzed.Results 324 cases/times of central catheterization were performed in 217 critical neonates,including 53 cases/times of umbilical artery catheterization(UAC),169 cases/times of umbilical vein catheterization(UVC),and 102 cases/times of peripherally inserted central catheters(PICC).There were 81 cases/times(25.0%)of central catheter-related AEs,and the rates of AEs in different central catheters were UVC(34.9%),UAC(15.1%) and PICC(13.7%) in descending order.The total number of days of UAC placement was 287 d,and the incidence of AEs per 1000 catheter days was 27.9‰.The total number of days of UVC catheterization was 1617 d,and the incidence of AEs per 1000 catheter days was 36.5‰.The total number of PICC catheterization days was 2245 d,and the incidence of AEs per 1000 catheter days was 6.2‰.Types and risk factors of UAC-AEs were failed catheter placement in 4 cases/times(7.5%),tip malposition in 2 cases/times(3.8%),and bloodstream infection(BSI) in 2 cases/times(3.8%).UAC-AEs occurred mainly at the time of catheterization,with failure of catheterization associated with tip malposition,with an incidence of BSI per 1000 catheter days of 7.0‰(2/287).Types and risk factors of UVC-AEs were tip malposition in 52 cases/times(30.8%),BSI in 3 cases/times(1.8%),pericardial effusion in 3 cases/times(1.8%) and pleural effusion in 1 case/time(0.6%).Pericardial effusion and pleural effusion most often occurred 2 to 3 d after catheterization and were considered to be related to vessel wall injury during catheterization and catheter tip elevation,with an incidence of BSI per 1000 catheter days of 1.9‰(3/1617).Further analysis of risk factors for UVC-BSI showed that the gestational age and birth weight of children with UVC-BSI were significantly lower than those of children with UVC-non-BSI,the catheter retention time was longer than that of children with UVC-non-BSI,and the proportion of children with gestational age <30 weeks and the incidence of pleural effusion were higher than those of children with UVC-non-BSI(P<0.05).Types and risk factors of PICC-AEs:4 cases/times(3.9%) of AEs occurred at the time of catheterization,including 1 case/time(1.0%) of failure of catheterization and 3 cases/times(2.9%) of tip malposition;10 cases/times(9.8%) of AEs occurred during the time of catheterization,including 5 cases/times(4.9%) of fluid extravasation,2 cases/times(2.0%) of catheter displacement,1 case/time(1.0%) of pleural effusion,1 case/time(1.0%) of pericardial effusion and 1 case/time(1.0%) of BSI.The incidence of BSI per 1000 catheter days was 0.4‰(1/2245);catheter displacement was the main cause of pericardial effusion and pleural effusion.Of the 324 cases/times of central catheterizations,21 cases/times(6.5%) were abnormal extubation,including 2 cases/times(3.8%) of UAC,15 cases/times(8.9%) of UVC,and 4 cases/times(3.9%) of PICC.Abnormal extubation of UVC or UAC occurred mostly at the time of catheterization and was related to the tip malposition;severe AEs during catheterization such as BSI,pericardial effusion,and increased infection indexes were the reasons for abnormal extubation of UVC,and pericardial effusion/pleural effusion due to fluid extravasation and catheter displacement were the main reasons for abnormal extubation of PICC.Conclusion The rate of umbilical catheter(UA) related AEs is still high,and tip malposition,fluid extravasation,and catheter displacement are risk factors for pericardial effusion and pleural effusion,and the combination of immediate ultrasound-guided evaluation of catheter tip position is an important clinical measure to reduce UC related AEs.