基于危重新生儿协作网中重庆5家三级甲等医院危重新生儿数据分析

目的 基于危重新生儿协作网（简称数据库）的数据，反映危重新生儿的诊治现状，为提高诊疗水平提供帮助。方法 数据库上报小早产儿、新生儿败血症、坏死性小肠结肠炎(NEC)、有创和无创机械通气治疗时间≥4 h的新生儿，且在上报医院住院时间≥24 h。根据上述4种疾病情况，设置一般信息、围生期情况、动脉导管未闭、神经系统、早产儿视网膜病变、氧气支持或呼吸机治疗、新生儿呼吸窘迫综合征（NRDS）、感染、炎性指标、抗感染治疗、NEC、转归11个模块用于分析，协作医院均安排专人负责数据的收集及录入和审核，并行统一培训。结果 2013年1月至2014年9月数据库纳入重庆5家三级甲等协作医院1 501例危重新生儿，小早产儿435例(29.0%)，新生儿败血症814例(542%)，NEC 343例(228%)，有创和无创机械通气治疗时间≥4 h新生儿742例(494%)，总体存活率为752%(1 129/1 501)。出生体重＜750 g、~999 g、~1 249 g、~1 499 g、≥1 500 g小早产儿存活率分别为500%（3/6）、565%（13/23）、654%（53/81）、749%（131/175）和820%（123/150）; ＜27、27~、28~、29~、30~、31~和≥32孕周的小早产儿存活率分别为231%（3/13）、650%（13/20）、694%（26/36）、712%（52/73）、718%（61/85）、809%（89/110）和816%（80/98）。315例（724%）小早产儿行头颅B超检查，其中生后3 d内完成检查占 453%（197例）。264（607%)使用机械通气，163例有创机械通气，101例单纯nCPAP。217例（499%）小早产儿发生NRDS。165/217例(760%)使用PS。74/813例（91%）使用碳青霉烯类抗生素时间>2周，预防与非预防使用碳青霉烯类抗生素存活率分别为889% (16/18)，875%(42/48)，差异无统计学意义（χ2=0024，P=1000）。数据库上报的1 501例病例中NEC 343例（229%），174例在腹胀10 d内能做出NEC诊断，313例行腹部X线片检查，仅有44例描述具有确诊意义的X线征象（肠壁积气、肠穿孔和肝门积气）。742例（494%）接受机械通气治疗，单纯无创机械通气180例，有创机械通气562例，无创机械通气和有创机械通气总体并发症发生率分别为11%（2/180）和174%（98/562）。结论 危重新生儿协作网对了解和提高中国危重新生儿诊疗水平有积极的探索性意义。危重新生儿诊治在3 d内行头颅B超检查、无创通气和践行气管插管-使用PS-拔管使用CPAP技术等方面需要进一步加强。

Analysis of critical ill neonates from 5 teritary A hospitals in Chongqing based on critical collaboration neonatal network

Objective To investigate the current status of critical ill newborns based on the data of critical neonatal collaboration network, to improve the level of diagnosis and treatment of critical ill newborns. Methods Data of small premature infants, neonatal sepsis, neonatal necrotizing enterocolitis (NEC) and invasive and non-invasive mechanical ventilation (treatment more than or equal to 4 h). Information of general information, perinatal information, patent ductus arteriosus (PDA), nervous system, retinopathy of prematurity (ROP), oxygen to support or ventilator in the treatment of neonatal respiratory distress syndrome (NRDS), infection and the inflammatory markers, anti infection treatment as well as NEC was abstracted from all recruited subjects. Unified training was conducted and responsible person was arranged for each collaborative hospitals for data collection, entry and verify. Results A total of 1 501 critical ill newborns from 5 hospitals from January 2013 to September 2014, including 435 cases of low birth weight premature, 814 cases of neonatal septicemia, 343 cases of NEC, 742 cases of invasive and non-invasive mechanical ventilation. The overall survival rate was 75.2% (1 129/1 501). According to birth weight, the survival rate was 50.0% (3/6), 56.5% (13/23), 65.4% (53/81), 74.9%(131/175) and 82.0(123/150) for the small preterm infants with birth weight < 750 g, -999 g, -1 249 g, -1 499 g, ≥1 500 g, respectively. According to the gestational age, the survival rate was 23.1% (3/13), 65.0% (13/20), 69.4% (26/36), 71.2% (52/73), 71.8% (61/85), 80.9%(89/110) and 81.6% (80/98) in the small preterm infants with gestational age < 27, 27-, 28-, 29-, 30-, 31- and ≥32 weeks. 315 cases (72.4%) received cerebral ultrasound examination, of them 45.3% (197 cases) was completed in 3 d after birth. 264 cases (60.7%) were treated with mechanical ventilation including 163 cases with invasive mechanical ventilation, 101 cases with only nCPAP. 217 cases (49.9%) were diagnosed as NRDS including 165 cases with PS treatment. 74/813 cases (9.1%) were treated with carbapenem antibiotic for more than 2 weeks. Survival rate did not significantly differed between the neonates treated with or without carbapenem antibiotics, 88.9% (16/18) vs 87.5%(42/48), χ2=0.024, P=1.000. Among 343 NEC neonates, 174 cases were diagnosed in 10 days of abdominal distension, only 44 cases had confirmed diagnostic significance among 313 cases taken abdominal X-ray examination. 742 cases (49.4%) received mechanical ventilation treatment, 180 cases with simple invasive ventilation and 562 cases with invasive ventilation. The overall complication rate significantly differed between the neonates treated with noninvasive mechanical ventilation and mechanical ventilation, 1.1%(2/180) vs 17.4%(98/562). Conclusion The critical neonatal collaboration network has positive significance for understanding and improving the level of diagnosis and treatment of critically ill newborns in China. The diagnosis and treatment of critical ill neonates and taking cerebral ultrasound examination in 3 days after birth, noninvasive ventilation and the practice of INSURE technology and other aspects need to be further strengthened.