新生儿重症监护室出生胎龄＜34周早产儿呼吸机相关肺炎的多中心流行病学调查

目的 调查我国新生儿呼吸机相关肺炎（VAP）的流行病学资料及病原菌分布特点.方法 分析2015年5月至2016年4月全国25家医院三级新生儿重症监护室（NICU）收治的出生胎龄＜34周所有患儿的临床资料,根据医院性质分组为儿童专科医院和妇婴医院或综合性医院,计算VAP发生率.采用x2检验,t检验或秩和检验进行统计学分析.结果 共纳入患儿7 918例,其中男4 623例（58.4％）,出生体重为（1 639 ±415）g,出生胎龄为（31.4±2.0）周,4 654例（58.8％）接受无创通气,2 154例（27.2％）接受有创机械通气.发生VAP 95例,总的VAP发生率为7.0/1 000个呼吸机使用日,各研究单位VAP发生率为（0-34.4）/1 000个呼吸机使用日.根据医院性质分组,7家儿童专科医院与18家妇婴医院或综合性医院VAP发生率差异无统计学意义[（9.6比6.0）/1 000个呼吸机使用日,t=1.002,P=0.327].检出病原菌83株,以革兰阴性杆菌（76株,91.6％）最常见,主要为鲍曼不动杆菌（24株,28.9％）,肺炎克雷伯杆菌（23株,27.7％）及铜绿假单胞菌（10株,12.0％）.结论 我国NICU平均VAP发生率接近发达国家水平,但不同医院之间差异显著,应加强各NICU医院内感染的定期监测和分析,在此基础上实施有效的感染综合防治措施,降低VAP发生率.

Global variation in skin injures and skincare practices in extremely preterm infants

Background Globally,are skincare practices and skin injuries in extremely preterm infants comparable?This study describes skin injuries,variation in skincare practices and investigates any association between them.Methods A web-based survey was conducted between February 2019 and August 2021.Quantifying skin injuries and describing skincare practices in extremely preterm infants were the main outcomes.The association between skin injuries and skincare practices was established using binary multivariable logistic regression adjusted for regions.Results Responses from 848 neonatal intensive care units,representing all geographic regions and income status groups were received.Diaper dermatitis(331/840,39%)and medical adhesive-related skin injuries(319/838,38%)were the most common injuries.Following a local skincare guideline reduced skin injuries[medical adhesive-related injuries:adjusted odds ratios(aOR)=0.63,95%confidence interval(CI)=0.45–0.88;perineal injuries:aOR=0.66,95%CI=0.45–0.96;local skin infections:OR=0.41,95%CI=0.26–0.65;chemical burns:OR=0.46,95%CI=0.26–0.83;thermal burns:OR=0.51,95%CI=0.27–0.96].Performing skin assessments at least every four hours reduced skin injuries(abrasion:aOR=0.48,95%CI=0.33–0.67;pressure:aOR=0.51,95%CI=0.34–0.78;diaper dermatitis:aOR=0.71,95%CI=0.51–0.99;perineal:aOR=0.52,95%CI=0.36–0.75).Regional and resource settings-based variations in skin injuries and skincare practices were observed.Conclusions Skin injuries were common in extremely preterm infants.Consistency in practice and improved surveillance appears to reduce the occurrence of these injuries.Better evidence regarding optimal practices is needed to reduce skin injuries and minimize practice variations.

加巴喷丁改善剖宫产术后疼痛管理：一项随机对照试验

背景加巴喷丁能够预防和治疗术后急性疼痛和慢性疼痛，但是，在剖宫产手术中的应用研究尚未见报道。本研究假设术前使用加巴喷丁能够减少剖宫产后疼痛。方法择期剖宫产患者随机分为两组：一组术前使用加巴喷丁600mg；另一组为安慰剂对照。蛛网膜下隙麻醉采用0．75％高比重布比卡因12mg，芬太尼10μg和吗啡100μg。术后镇痛开始于术中使用酮咯酸和对乙酰氨基酚，并于术后使用双氯芬酸、对乙酰氨基酚和吗啡。采用视觉模拟评分量表（0-100ram）评估麻醉后6小时、12小时、24小时以及48小时的静息痛和活动痛，记录患者满意度、阿片类药物用量和副作用。并记录新生儿干预治疗、Apgar评分、脐动脉血气分析和母乳喂养困难等情况。慢性疼痛在分娩后3个月进行评估，测定试验亚组中产妇和脐静脉加巴喷丁血浓度。采用混合模型分析，比较组间24小时疼痛视觉模拟评分的主要结果。结果46例患者随机分组，2例在分析时被排除。加巴喷丁组24小时平均（95％可信区间）运动疼痛评分为21mm（13-28），安慰剂对照组为41mm（31-50），P=0．001。加巴喷丁组产妇满意度较高。两组阿片类药物的用量无差异，但是加巴喷丁组产妇重度镇静比安慰剂对照组更常见（发生率分别为19％和0％，P=0．04）。新生儿Apgar评分、干预治疗或脐动脉pH值组间比较无统计学差异。产妇静脉／脐静脉血浆加巴喷丁浓度比的平均值和标准差分别为0．86和0．12。术后3个月两组慢性疼痛发生率类似。结论多模式镇痛中，术前口服加巴喷丁600mg与安慰剂对照组相比，可降低剖宫产术后疼痛，提高产妇满意度。