摘要
目的探讨2017年至2019年极低出生体重儿(very low birth weight infant,VLBWI)复苏质量改进情况及其对复苏效果的影响。方法回顾性纳入2017年1月1日至2019年12月31日在重庆市妇幼保健院出生并转入新生儿重症监护病房的VLBWI 318例。按照具体复苏策略实施情况分为3组:2017年为复苏质量改进前(n=83),2018年为改进中(n=102),2019年为改进后(n=133)。分析比较各年复苏策略,包括体温管理、延迟脐带结扎(delayed cord clamping,DCC)、呼吸支持[产房持续气道正压通气(continuous positive airway pressure,CPAP)、正压通气或气管插管使用]和氧疗[复苏初始吸入氧浓度(fraction of inspired oxygen,FiO2)、复苏最高FiO2以及纯氧复苏]实施情况、复苏效果及转归。采用趋势χ2检验、Kruskal-Wallis H检验、Wilcoxon轶和检验、方差分析及LSD检验进行统计分析。结果(1)母亲产前足疗程糖皮质激素使用比例在2017年至2019年逐年上升[44.6%(37/83)、47.1%(48/102)与72.2%(96/133),χ2趋势=18.218,P<0.001]。(2)入院时低体温比例逐年下降[100.0%(83/83)、90.2%(92/102)与33.8%(45/133),χ2趋势=136.042,P<0.001],且并未增加体温过高比例[0.0%(0/83)、1.0%(1/102)与0.0%(0/133),χ2趋势=2.124,P=0.346]。(3)DCC比例逐年增加[0.0%(0/83)、29.4%(30/102)与90.2%(120/133),χ2趋势=178.659,P<0.001],生后12~24 h毛细血管血血红蛋白含量逐年上升[(190.1±34.8)、(202.0±29.7)与(213.6±32.3)g/L,LSD检验,P值均<0.05]。疑似红细胞增多症(毛细血管血红细胞压积>68%)发生率逐年增加[7.2%(6/83)、7.8%(8/102)与17.3(23/133),χ2趋势=5.825,P=0.016];除外没有检测静脉血红细胞压积的病例,2017、2018和2019年VLBWI红细胞增多症确诊(静脉血红细胞压积>65%)率并未增加[1.3%(1/80)、2.0%(2/100)与4.8%(6/126),χ2趋势=2.333,P=0.127]。(4)产房CPAP使用比例逐年增加[0.0%(0/83)、28.4%(29/102)与87.2%(116/133),χ2趋势=167.721,P<0.001];产房内正压通气比例[44.6%(37/83)、31.9%(32/102)与28.6%(38/133),χ2趋势=5.371]、生后1 min内气管插管比例[100.0%(31/31)、45.0%(9/20)与35.0%(7/20),χ2趋势=37.467]和总气管插管比例[37.3%(31/83)、19.6%(20/102)与15.0%(20/133),χ2趋势=13.566]均逐年下降(P值均<0.05);但胸外按压、肾上腺素使用以及低Apgar评分比例各年差异无统计学意义(P值均>0.05)。(5)与2017年相比,2018年和2019年复苏初始FiO2[30%(21%~100%),30%(21%~100%)与40%(25%~100%)]、最高FiO2[40%(21%~100%),30%(21%~100%)与40%(25%~100%)]均明显降低(P值均<0.017),纯氧复苏比例逐年下降[13.3%(11/83)、1.0%(1/102)与0.8%(1/133),χ2趋势=17.719,P<0.001]。各年桡动脉血气分析结果、住院期间肺表面活性物质、机械通气应用比例、最高经皮胆红素值以及高胆红素血症、坏死性小肠结肠炎、脑室周围-脑室内出血、支气管肺发育不良发生率和病死率差异无统计学意义(P值均>0.05)。结论随着复苏质量改进措施的陆续应用,降低了VLBWI入院低体温的发生,提高了生后血红蛋白值,减少了正压通气和气管插管的比例,且对复苏效果无影响,也不增加短期不良结局。
Objective To understand quality improvement(QI)in resuscitation and its impacts on the outcomes in very low birth weight infants(VLBWI).Methods This was a retrospective study involving 318 cases of VLBWI born in Chongqing Health Center for Women and Children and transferred to the Neonatal Intensive Care Unit(NICU)in the same hospital from January 1,2017 to December 31,2019.All recruited VLBWIs were divided into three groups based on chronological order:pre-QI group(born in 2017,n=83),under-QI group(born in 2018,n=102)and post-QI group(born in 2019,n=133).The implementation and effects of different resuscitation strategies,including body temperature management,delayed cord clamping(DCC),respiratory support[continuous positive airway pressure(CPAP)in the delivery room,positive pressure ventilation or tracheal intubation]and oxygen therapy[initial fraction of inspired oxygen(FiO2),maximum FiO2 and pure oxygen resuscitation],and the neonatal outcomes in each year were analyzed and compared by trend Chi-square test,Kruskal-Wallis H test,Wilcoxon rank-sum test,analysis of variance and LSD test.Results(1)The proportion of antenatal steroid exposure increased gradually during the three years[44.6%(37/83),47.1%(48/102),72.2%(96/133);χ2trend=18.218,P<0.001].(2)From 2017 to 2019,the incidence of hypothermia on admission decreased[100.0%(83/83),90.2%(92/102),33.8%(45/133);χ2trend=136.042,P<0.001],without increasing the proportion of hyperthermia[0.0%(0/83),1.0%(1/102),0.0%(0/133);χ2trend=2.124,P=0.346].(3)The proportion of VLBWIs receiving DCC increased annually[0.0%(0/83),29.4%(30/102),90.2%(120/133);χ2trend=178.659,P<0.001],and the concentration of capillary hemoglobin within 12-24 h after birth also increased[(190.1±34.8),(202.0±29.7),(213.6±32.3)g/L;LSD test,P<0.05].The incidence of suspected polycythemia(capillary hematocrit>68%)increased annually[7.2%(6/83),7.8%(8/102),17.3(23/133);χ2trend=5.825,P=0.016];While the incidence of confirmed polycythemia(venous hematocrit>65%)was not increased[1.3%(1/80),2.0%(2/100),4.8%(6/126);χ2trend=2.333,P=0.127]after excluding those untested cases.(4)The use of CPAP in delivery room increased annually[0.0%(0/83),28.4%(29/102),87.2%(116/133);χ2trend=167.721,P<0.001],while that of positive pressure ventilation[44.6%(37/83),31.9%(32/102),28.6%(38/133);χ2trend=5.371,P=0.020],and the proportion of intubation within 1 min after birth[100.0%(31/31),45.0%(9/20),35.0%(7/20);χ2trend=37.467,P<0.001]and overall intubation[37.3%(31/83),19.6%(20/102),15.0%(20/133);χ2trend=13.566,P<0.001]decreased year by year.There was no difference in the percentage of infants receiving chest compression or epinephrine,or with low Apgar scores during the three years(all P>0.05).(5)The initial inhaled FiO2[30%(21%-100%),30%(21%-100%)vs 40(25%-100%)]as well as the highest FiO2[40%(21%-100%),30%(21%-100%)vs 40%(25%-100%)]were significantly lower in 2018 and 2019 than in 2017(all P<0.017).The proportion of infants receiving pure oxygen resuscitation decreased year by year[13.3%(11/83),1.0%(1/102),0.8%(1/133);χ2trend=17.719,P<0.001].There was no statistical difference in radial artery blood gas analysis,the proportion of infants receiving pulmonary surfactant or mechanical ventilation,the highest value of percutaneous bilirubin,the incidence of hyperbilirubinemia,necrotizing enterocolitis,periventricular intraventricular hemorrhage,bronchopulmonary dysplasia,or mortality during hospitalization(all P>0.05).Conclusions Resuscitation QI program helps reduce the incidence of hypothermia,increased the hemoglobin level after birth,and lessen the use of positive pressure ventilation and tracheal intubation in VLBWIs,without influencing the resuscitation effect or increasing the risk of short-term adverse outcomes.
作者
欧姜凤
钟晓云
吴艳
章晓婷
龚华
陈文
Ou Jiangfeng;Zhong Xiaoyun;Wu Yan;Zhang Xiaoting;Gong Hua;Chen Wen(Department of Neonatology,Chongqing Health Center for Women and Children,Chongqing 401147,China)
出处
《中华围产医学杂志》
CAS
CSCD
北大核心
2020年第9期600-607,共8页
Chinese Journal of Perinatal Medicine
关键词
婴儿
极低出生体重
复苏术
质量改进
治疗结果
Infant,very low birth weight
Resuscitation
Quality improvement
Treatment outcome
