How well do diagnosis‐related groups perform in the case of extremely low birthweight neonates?

OBJECTIVE: To determine how well diagnosis related groups (DRG) perform for extremely low birthweight neonates, by examining length of stay (LOS) data for babies with birthweight of 750-999 g and managed in the seven New South Wales maternity hospital neonatal intensive care units (NICU). METHODOLOGY: Neonates with an admission weight of 750-999 g and admitted to one of the seven NICU were studied. Those who died or were transferred in the first 5 days were excluded, leaving the group of neonates defined by DRG P62Z. In order to allow comparisons between the different NICU, neonates whose care was split between two or more NICU were also excluded, leaving those who either died, were transferred to a nursery closer to their home or were discharged directly to their home. The relationship between LOS and a number of perinatal factors was studied for the total group, and LOS data were compared for individual hospitals. RESULTS: Length of stay was most strongly associated with mode of separation. It was also significantly associated with gestational age, time ventilated, oxygen need at 36 weeks postconceptual age, and retinopathy of prematurity. Neonatal intensive care units with the highest proportion of neonates being transferred had the lowest average LOS, and vice versa. CONCLUSIONS: The LOS of neonates in DRG P62Z is more strongly related to mode of separation (died, transferred or discharged home) than to factors that reflect best practice. A funding model that rewards NICU for a short LOS may unfairly disadvantage some units while favouring others.     

Risk factors and pathogen profile of ventilator‐associated pneumonia in a neonatal intensive care unit in China

Background: The aim of the present study was to explore the incidence and risk factors of, and summarize the involved pathogens in, neonates with ventilator‐associated pneumonia (VAP) in the authors' neonatal intensive care unit (NICU) to determine the effective strategies for prevention. Methods: A retrospective case–control study including 117 VAP patients and 232 controls was conducted from January 2002 to July 2008. The antibiotics sensitivity spectrum was determined on quantitative microbiological evaluation. Multiple logistic regression and Cox model analysis were performed to determine independent and accumulative risk factors for VAP. Results: Multivariate analysis showed that birthweight, mechanical ventilation (MV), parenteral alimentation, dexamethasone and other respiratory disease were associated with the development of VAP. The cumulative risk for developing VAP increased over the duration of stay in the NICU. The most common isolated bacteria of the pathogen spectrum in VAP were Klebsiella spp. (33/146), Acinetobacter baumannii (26/146), Pseudomonas aeruginosa (18/146) and Staphylococcus aureus(13/146). Meanwhile, we found that previous use of antibiotics before VAP diagnosis was not associated with the onset of VAP. Conclusions: The daily risk for VAP increases with duration of stay in the NICU after ventilation. Drug‐resistant bacteria are common pathogens for neonatal VAP in the authors' NICU.     

血清降钙素原在新生儿呼吸机相关性肺炎诊治中的意义

目的 探讨血清降钙素原（procalcitonin,PCT）在新生儿呼吸机相关性肺炎（ventilator associated pneumonia,VAP）诊治中的价值.方法 按照7d内是否发生VAP,将2012年1月至2013年12月入住我院NICU需有创机械通气的60例患儿分为VAP组（30例）和非VAP组（30例）,VAP组患儿再按照随机数字表法随机分为PCT组（15例）和对照组（15例）.两组患儿于机械通气前及机械通气后测定血清PCT、C反应蛋白（C-reactive protein,CRP）及WBC计数,比较各炎症指标对VAP诊断的敏感性、特异性、阳性预测值和阴性预测值.结果 VAP组患儿机械通气前后血清PCT水平比较差异有统计学意义（t=1.58,P=O.000）,分别为（0.37±0.25） μg/L和（2.17±1.46） μg/L;非VAP组机械通气前后PCT水平无明显变化（t=3.67,P=0.055）.两组患儿机械通气前后血清CRP与WBC计数差异均无统计学意义（P均＞0.05）.以PCT≥0.40 μg/L、CRP≥28 mg/L、WBC≥10×109/L为阳性阈值,三指标对诊断VAP的敏感性分别为93.3％、73.3％、66.7％,其中PCT的特异性为73.3％,阳性预测值为77.8％,阴性预测值为91.7％.PCT组和对照组抗生素使用时间分别为（12.6±5.6）d和（15.1±9.1）d,两者差异有统计学意义（P=0.018）.结论 血清PCT在VAP诊断中有较高的敏感性和特异性,PCT联合临床肺部感染评分可以提高VAP诊断的准确性,及时监测血清PCT有助于VAP的早期诊断,以血清PCT指导抗生素治疗可缩短抗生素疗程.     

Ventilator-associated pneumonia in a paediatric intensive care unit in a developing country with high HIV prevalence

Aim:   To obtain preliminary prevalence, aetiological and outcome data on South African paediatric patients with ventilator-associated pneumonia (VAP).
Methods:   Non-bronchoscopic bronchoalveolar lavage (BAL) specimens taken between January 2004 and September 2005 were prospectively recorded and related clinical data were retrospectively reviewed. VAP was defined as a new isolate on BAL and a modified Clinical Pulmonary Infection Score ≥5.
Results:   A total of 230 patients aged 3.9 (2.2–9.1) months (median interquartile range (IQR) ) underwent 309 BALs during 244 paediatric intensive care unit (PICU) admissions. Most patients (84%) were admitted with acute infectious diseases, with a 70% incidence of comorbidity. Thirty-three patients (14.3%) were HIV-exposed but uninfected and 58 (25.2%) were HIV-infected.
Of 172 BALs taken ≥48 h after intubation, 63 specimens from 55 patients fulfilled VAP criteria. Acinetobacter baumannii was the most common VAP pathogen, followed by Klebsiella pneumoniae , viruses, yeasts and Staphylococcus aureus.
Patients who developed VAP had a higher proportion of comorbid conditions (76% vs. 55%, P = 0.01) and reintubations (39% vs. 12%, P < 0.0001) when compared with non-VAP patients. Median (IQR) length of PICU stay was 12.5 (5–21) days versus 8 (5–14) days ( P = 0.03); and the risk adjusted PICU mortality was 1.38 versus 0.79 ( P = 0.002) in VAP versus non-VAP patients, respectively.
Conclusions:   VAP is associated with significant morbidity and mortality and may relate to the high incidence of comorbid conditions in this population. Primary VAP pathogens differ from developed countries.     

选择性剖宫产与足月儿呼吸窘迫综合征回顾性分析

目的 探讨选择性剖宫产对足月儿呼吸窘迫综合征(RDS)发生的影响,并比较两中心足月儿RDS发生情况及相关影响因素.方法 以2006年6月至2008年6月,在浙江大学附属儿童医院NICU及新生儿病房(A中心)和浙江大学附属妇产科医院NICU(B中心)收治的足月儿RDS为研究对象,分析选择性剖宫产RDS的胎龄分布、所有病例有并发症组与无并发症组的比较,以及两中心临床资料的分析比较.计数资料行χ~2检验,计量资料行t检验.结果 90例足月儿RDS中88例为选择性剖宫产,占97.8%,39、40周以后的RDS构成比明显低于37周及38周时.经losistic回归分析,开始上机时间12 h是足月儿RDS发生并发症的主要危险因素(OR=12.667,P=0.021).两中心的病例在入院年龄(t=11.833,P=0.001)、胸部X线分期(χ~2=4.85,P=0.028)、PS应用(t=11.911,P=0.002)、开始上机时间(t=10.051,P=0.018)、上机前PaO_2/FiO_2(χ~2=4.184,P=0.005)、OI>25(t=4.737,P=0.03)、用氧时间(χ~2=10.475,P=0.001)、并发低血压(t=11.020,P=0.01)以及住院时间(t=9.872,P=0.002)等均存在显著性差异.结论 选择性剖宫产是足月儿RDS发生的重要影响因素,早期诊断、早期干预可以减少足月儿RDS的并发症.     

新生儿呼吸机相关性肺炎的临床研究

目的 了解新生儿呼吸机相关性肺炎(VAP)的临床特征和高危因素,为VAP的预防和治疗提供借鉴.方法 对2005年1月至2006年12月入住华盛顿大学医学院圣路易斯儿童医院NICU的所有新生儿临床资料进行回顾性分析.结果 682例接受了机械通气的患儿中,527例机械通气时间≥148 h,其中发生VAP 79例,按体质量分层的每1 000个呼吸机通气日VAP发生率分别是≤1 000 g组6.3,1 001～1 500 g组5.8,1 501～2 500 g组5.6,＞2 500 g组3.6.病原菌以革兰阴性杆菌为主,占86.09%,其中最常见的是铜绿假单胞菌、肠杆菌、肺炎克雷白菌、嗜麦芽窄食单胞菌和黏质沙雷菌.革兰阳性球菌主要为肠球菌和金黄色葡萄球菌.Logistic回归分析发现,低胎龄和机械通气时间是新生儿VAP的独立预测因素,OR及95%CI分别是0.886(0.839～0.943)和1.037(1.027～1.046).结论 VAP在低胎龄儿中发生率较高,可能是导致其住院时间延长的原因之一;尽可能缩短机械通气时间可能会降低VAP的发生率.     

新生儿呼吸机相关性肺炎的病原学和高危因素分析

目的：随着现代儿科急救医学和新生儿医学的发展, 新生儿呼吸机相关性肺炎(VAP)作为NICU内主要的医院获得性感染已日益受到重视。由于VAP发病机制的复杂性,目前国内关于VAP的高危因素研究较少。该研究旨在初步探讨VAP的发病率﹑病原学和高危因素, 为VAP的防治提供一定的理论依据。方法：回顾分析2003～2005年南昌大学第一附属医院NICU呼吸机治疗的106例危重新生儿的临床资料。结果：VAP发病率为41.7％,单因素分析发现早产儿、低体重、机械通气时间、原发肺部疾患、再插管、有无大剂量使用丙种球蛋白等因素与VAP有关(P＜0.05）。Logistic回归确定机械通气时间、原发肺部疾患、再插管、有无大剂量使用丙种球蛋白为VAP影响因素(P＜0.05）。病原菌主要是耐药性条件致病菌,以革兰阴性杆菌为主(76.9％)。结论：致病菌主要是耐药性条件致病菌;VAP的高危因素众多,其发病机制复杂,是外部环境与患者内环境因素综合作用的结果,采取综合防治措施可能是控制VAP的最佳策略。［中国当代儿科杂志,2007,9（6）：549-552］     

Short Term Outcome of Neonates Born With Abnormal Umbilical Cord Arterial Blood Gases

Background:

Umbilical arterial blood gas (UABG) analysis is more objective than other methods for predicting neonatal outcome. Acidemic neonates may be at risk for unfavorable outcome after birth, but all neonates with abnormal arterial blood gas (ABG) analysis do not always have poor outcome.

Objectives:

This study was carried out to determine the short term outcome of the neonates born with an abnormal ABG.

Patients and Methods:

In a cohort prospective study 120 high risk mother-neonate pairs were enrolled and UABG was taken immediately after birth. All neonates with an umbilical cord pH less than 7.2 were considered as case group and more than 7.2 as controls. Outcomes like need to resuscitation, admission to newborn services and/or NICU), seizure occurrence, hypoxic ischemic encephalopathy (HIE), delayed initiation of oral feeding and length of hospital stay were recorded and compared between the two groups. P value less than 0.05 was considered as being significant.

Results:

Comparison of short term outcomes between normal and abnormal ABG groups were as the fallowing: need for advanced resuscitation 4 vs. 0 (P = 0.001), NICU admission 16 vs. 4 (P = 0.001), convulsion 2 vs. 0 (P = 0.496), HIE 17 vs. 4 (P = 0.002), delay to start oral feeding 16 vs. 4 (P = 0.001), mean hospital stay 4 vs. 3 days (P = 0.001). None of the neonates died in study groups.

Conclusions:

An umbilical cord PH less than 7.2 immediately after birth can be used as a prognostic factor for unfavorable short term outcome in newborns.     

新生儿呼吸机相关性肺炎病原菌及危险因素分析

目的：分析新生儿呼吸机相关性肺炎（VAP）的病原菌、药敏情况及危险因素。方法：对2008年1月至2012年2月入住新生儿重症监护病房（NICU）机械通气时间≥48 h的401例患儿的临床资料进行回顾性分析,其中85例患儿发生了VAP。结果：革兰阴性菌为VAP的主要致病菌（97%）,前3位致病菌依次为肺炎克雷伯菌（51%）、鲍曼不动杆菌（17%）、大肠埃希菌（12%）。药敏试验显示病原菌对临床常用抗菌药物阿莫西林、阿莫西林/克拉维酸、哌拉西林、头孢他啶、头孢唑林、头孢噻肟等均耐药（药敏率<15%）,且对亚胺培南、美洛培南的药物敏感性明显下降（药敏率<75%）。出生体重(OR=1.399,P<0.05)、机械通气时间（OR=1.966,P<0.01)、住院时间（OR=1.812,P<0.01)、插管次数（OR=2.056,P<0.01）、1 min Apgar评分（OR=2.146,P<0.01）为新生儿VAP的独立危险因素。结论：新生儿VAP的发生受多种因素的影响,其致病菌以革兰阴性菌为主,临床上应根据药敏试验结果合理使用抗菌药物,同时采取综合防治措施,有效减少VAP的发生。     

Rooming‐in for preterm infants: How far should we go? Five‐year experience at a tertiary hospital

Aim: To determine the rate of rooming-in among preterm infants born in a tertiary hospital. Methods: We reviewed the records of all preterm infants born at our hospital during a 5-y period, 2000 to 2004. Results: Of the 18953 neonates born at our institution during this time, 1356 (7.2%) were <37 wk gestational age. Considering only preterm infants with birthweight 1500 g, 806 (74.1%) stayed with their mothers and 282 (25.9%) were admitted to the NICU. Of all the preterm infants that initially stayed with their mothers, 42 (5.2%) needed to be transferred to the NICU. When we stratified these preterm infants according to birthweight, we found that 29% of those <1750 g were transferred to the NICU, compared to only 5% of those 1750 g.
Conclusion: Our study supports the idea that the majority of preterm infants, especially those with birthweight <1750 g, can safely remain near their mothers at all times during hospital stay, with both clinical and financial benefits. Neonates with birthweight <1750 g should be evaluated carefully to decide whether rooming-in is the best option. Rooming-in should be encouraged in preterm infants.     

Epidemiology of nosocomial infections in neonates]

Epidemiology of nosocomial infections in neonates has to be described according to our definitions (early onset GBS diseases excluded) and according to levels of care. Nosocomial risk exists in maternity departments (3% in postnatal beds), incidence rates are 7.5-12.7% or 1.3-8.5 per 1000 days in neonatal care units and 14.2% or 11.7 per 1000 days in neonatal intensive care units (NICU). Gram-positive cocci bloodstream infections are the most common nosocomial infections in NICU but viral gastroenteritis are more frequent in neonatal care units. Risk factors are low birthweight, small gestational age and intravascular catheter in NICU, and for viral nosocomial infections, visits and winter outbreaks.     

Ventilator Associated Pneumonia in Critically-Ill Neonates Admitted To Neonatal Intensive Care Unit,Zagazig University Hospitals

Objective

ventilator associated pneumonia (VAP) is defined as nosocomial pneumonia in mechanically ventilated patients. It is considered to be most important cause of infection-related death in intensive care unit. We studied the characteristics and risk factors of VAP in critically-ill neonates.

Methods

Fifty six consecutive neonates with different diagnosis admitted from January to October 2010 to neonatal intensive care unit (NICU), Zagazig University Hospitals who needed mechanical ventilation were included in the study. There were 32 neonates, 18 males and 14 females with proven diagnosis of VAP, and 24 neonates, 11 males and 13 females without VAP served as control group. All studied neonates were subjected to history taking, clinical examination, routine investigations (Complete blood count, C-reactive protein, arterial blood gases, blood culture and liver and kidney function tests), and chest X-ray daily as well as non-bronchoscopic alveolar lavage culture for VAP group only.

Findings

Of 56 neonates who needed mechanical ventilation, 57.1% developed VAP. Prematurity, low birth weight and prolonged duration of mechanical ventilation were risk factors for developing VAP. Increased total leucocytic count, CRP and hypoalbuminemia were significantly presented in VAP-group. There were significant differences between VAP and non-VAP groups regarding hypothermia, mucopurulent endotracheal tube secretion, PaCO₂ and PaO₂. Microorganisms associated with blood stream infection in VAP diagnosed group were Klebsiella (15.6%), S. aureus (12.5%), Pseudomonas (9.4%), E. coli (6.2%), Candida (3.1%); 53.1% of obtained blood cultures were sterile. Of non-bronchoscopic alveolar lavage cultures obtained from VAP patients, 68.6% showed gram negative infection, 21.8% showed gram positive organisms and 9.3% revealed Candida infection.

Conclusion

The most important risk factors of VAP are prematurity, low birth weight, prolonged duration of mechanical ventilation, enteral nutrition and umbilical catheterization.     

Another outcome of neonatal intensive care: First year mortality and hospital morbidity

Objectives: To determine first year mortality and hospital morbidity after neonatal intensive care.
Methodology: Cohort study of 6077 surviving infants inborn in one regional hospital in 1988. Nine hundred and eighty-eight received neonatal intensive care and 103 were very low birthweight (VLBW).
Results For infants who required care in the neonatal intensive care unit (NICU), the relative risk of dying before their first birthday was 3.6 (95% confidence intervals [Cl] 1.5-8.8). This increased risk was associated with low birthweight (LBW) rather than requirement for NICU care. Of all inborn survivors, 10.4% were readmitted to hospital in the first year and 2.4% more than once. The readmission rate was 20% for NICU survivors and 30% for VLBW infants. The risk of hospitalization was independently associated both with NICU admission (odds ratio 2.3, Cl 1.9-2.9) and with VLBW (OR 1.8, Cl 1.1-3.0). The NICU survivors also had multiple admissions and prolonged hospital stays.
Conclusions Both low birthweight and neonatal illness requiring intensive care are important indicators of continuing medical vulnerability over the first year of life.     

Current status of unplanned readmission of neonates within 31 days after discharge from the neonatal intensive care unit and risk factors for readmission北大核心CSCD

目的 了解新生儿重症监护室（neonatal intensive care unit，NICU）患儿出院31 d内非计划再入院现状及其影响因素，为制定相关预防策略提供参考。 方法 回顾性收集1 561例NICU出院患儿临床资料，将31 d内发生再次入院的52例患儿作为病例组，采用1∶2病例对照研究的方法，选取同期住院后未发生再入院病例104例作为对照组，对两组患儿的临床资料行单因素分析和多因素logistic回归分析。 结果 1 561例患儿中，52例患儿共发生再入院63次，再入院率为3.33%。高胆红素血症和肺炎是再入院的主要原因，分别占29%（18/63）和24%（15/63）。多因素logistic回归分析结果显示，胎龄<28周、出生体重<1 500 g、多胎妊娠、机械通气、住院时间≤7 d是NICU出院患儿再入院的影响因素（分别OR值为5.645、5.750、3.044、3.331、1.718，P<0.05）。 结论 NICU出院患儿再入院风险较高，医护人员应关注其影响因素，制订针对性干预措施，减少再入院次数，提高医疗服务质量。     

一所地市级医院NICU中新生儿肺出血的高危因素分析

目的探讨某地市级医院NICU中发生新生儿肺出血(NPH)高危因素,为地市级医院救治NPH提供早期识别依据。方法某地市级医院NICU确诊的112例NPH患儿作为病例组,按巢式病例配对法选取同期住院、予呼吸机辅助呼吸但未并发生肺出血的224例新生儿为对照组,采用单因素分析和非条件logistic回归分析法对NPH的高危因素进行统计学分析。结果单因素分析结果显示:病例组母妊娠期糖尿病及胆汁淤积症,患儿剖腹产出生,胎龄34周,5 min Apgar评分≤5分,体重2 500 g,NPH前出现心力衰竭、弥漫性血管内凝血(DIC)、PaO_2/FiO_2(氧合指数,OI)≤100及平均血小板体积减小的发生比率明显高于对照组。Logistic回归多因素分析显示:DIC、心力衰竭、OI≤100是NPH的独立危险因素(OR分别为33.975、3.975、1.818;P0.05)。结论心力衰竭、OI≤100、DIC是地市级医院NICU发生NPH高危因素,应针对这些因素开展积极的原发病治疗和病情监测。     

Inhaled nitric oxide therapy during the transport of neonates with persistent pulmonary hypertension or severe hypoxic respiratory failure

Our aim was to determine whether starting inhaled nitric oxide (iNO) on critically ill neonates with severe hypoxemic respiratory failure and/or persistent pulmonary hypertension (PPH), at a referring hospital at the start of transport, decreases the need for extracorporeal membrane oxygenation (ECMO), lessens the number of hospital days and improves survival in comparison with those patients who were started on iNO only at the receiving facility. The study was a retrospective review of 94 charts of neonates that had iNO initiated by the transport team at a referring hospital or only at the tertiary neonatal intensive care unit (NICU) of the receiving hospital. Data collected included demographics, mode of transport, total number of hospital days, days on inhaled nitric oxide and ECMO use. Of the 94 patients, 88 were included. Of these, 60 were started on iNO at the referring facility (Field-iNO) and 28 were started at the receiving NICU (CHLA-iNO). All patients survived transport to the receiving NICU. Death rates and ECMO use were similar in both groups. Overall, patients who died were younger and had lower birth weights and Apgar scores. For all surviving patients who did not require ECMO, the length of total hospital stay (median days 22 versus 38, P = 0.018), and the length of the hospital stay at the receiving hospital (median days 18 versus 29, P = 0.006), were significantly shorter for the Field-iNO patients than for the CHLA-iNO patients, respectively. Earlier initiation of iNO may decrease length of hospital stay in surviving neonates with PPH not requiring ECMO.     

新生儿呼吸窘迫综合征合并呼吸机相关肺炎患儿气道灌洗液IL-4和IL-13水平监测

目的：通过监测新生儿呼吸窘迫综合征（RDS）患儿呼吸机相关肺炎（VAP）气道灌洗液中IL-4和IL-13含量,了解发生VAP时免疫调节功能。方法：68名机械通气>48 h的RDS新生儿作为研究对象,其中发生VAP的患儿37名,未发生VAP的31名。用ELISA法测定机械通气后1 h,72 h及96 h支气管肺泡灌洗液中IL-4和IL-13 水平。结果：机械通气后96 h VAP组支气管肺泡灌洗液中IL-4水平显著高于非VAP组（35.34±1.78 ng/L vs 13.69±2.47 ng/L; P<0.05）; IL-13水平亦显著高于非VAP组（33.74±2.74 ng/L vs 13.50±3.81 ng/L; P<0.05）。随着上机时间的延长,VAP组支气管肺泡灌洗液中IL-4及IL-13含量逐渐增加,上机后96 h与1 h比较差异均有显著性（P<0.05）。结论：新生儿RDS患儿在合并VAP时支气管灌洗液中IL-4及IL-13浓度增高,提示IL-4及IL-13参与了体内免疫反应的调节。［中国当代儿科杂志,2009,11（8）：645-648］     

新生儿重症监护室医源性皮肤损伤多中心横断面调查

背景：医源性皮肤损伤是入住NICU的新生儿面临的常见问题。目的：了解我国NICU内新生儿医源性皮肤损伤的发生率。设计：横断面调查。方法：建立NICU新生儿的医源性皮肤损伤临床资料数据库（简称数据库）,由复旦大学附属儿科医院NICU牵头,包括中国15个省、自治区、直辖市的22家三级甲等医院（简称协作医院）NICU。将医源性皮肤损伤的原因归纳为7类：尿布相关、粘胶相关、压力相关（包括医疗器械相关）、外科手术相关、血管通路相关、各种理化因素相关、其他。数据库上报的对象为协作医院NICU的连续病例,上报数据均来源于所在医院电子病历系统或纸质医疗文书记录。数据上报项目：一般资料,各种医疗器械使用情况,医源性皮肤损伤事件,每次医源性皮肤损伤发生时的日龄、体重、住院时长,皮肤损伤的部位、大小、类型、颜色、处理措施和预后。由牵头医院针对数据库上报指标对协作医院进行培训并考核合格后开始数据的收集并审核。主要结局指标：医源性皮肤损伤发生率。结果：2019年12月1日至2020年1月31日22家协作医院收集的NICU连续病例（n=8 126）数据全部合格,纳入本文分析。其中医源性皮肤损伤521例（6.4%）,儿童专科医院、综合性医院和妇幼保健院的NICU医源性皮肤损伤的发生率分别为7.4%（280/3 783）、6.4%（153/2 387）和4.5%（88/1 956）。521例共发生566例次医源性皮肤损伤,发生2次医源性皮肤损伤45例（8.6%）。医源性皮肤损伤发生日龄中位数为6(3,17)d,生后1周内发生者占57.4%（299例）;发生医源性皮肤损伤的新生儿入院纠正胎龄中位数为37.2（32.7,40.0）周,纠正胎龄≥37周占56.4%（294例）;发生医源性皮肤损伤时的体重中位数为2 800(1 912~3 450)g,体重≥2 500 g占59.1%（308例）。尿布相关250例（48.0%）,压力相关（包括医疗器械相关）81例（15.5%）,粘胶相关69例（13.2%）,各种理化因素相关70例（13.4%）,血管通路相关22例（4.2%）,外科手术相关性14例（2.7%）,其他15例（2.9%）。日龄1~7 d新生儿发生各类医源性皮肤损伤的占比最高;除压力相关性皮肤损伤易发生于极低出生体重儿、医源粘胶相关性皮肤损伤在各体重组都易发生之外,其他类型的皮肤损伤均多发生于体重≥2 500 g的新生儿;压力相关性、粘胶相关性皮肤损伤多发生于纠正胎龄28～32周的新生儿,血管通路相关性皮肤损伤在各纠正胎龄分组中的占比较均匀,其他皮肤损伤好发于纠正胎龄＞32周的新生儿;78.9%的医源性皮肤损伤发生时的住院时间＜1周,随着时间的推移,发生比例逐周下降。结论：我国NICU新生儿医源性皮肤损伤发生率为6.4%。尿布相关性皮炎、医疗器械应用及医疗胶布的使用是新生儿发生医源性皮肤损伤的三大主要因素。医源性皮肤损伤受胎龄、出生体重、各种导管的使用等多因素影响。     

Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: a meta-analysis of observational studies

Ventilator-associated pneumonia (VAP) is a common and serious problem among mechanically ventilated patients in intensive care units (ICU), especially for the newborn. However, limited literatures have been reviewed to synthesize the finding of previous papers to investigate the risk factors for VAP although it has been a serious complication of mechanical ventilation (MV) with a high morbidity and mortality in the newborn. We performed this meta-analysis to extend previous knowledge for developing VAP prevention strategies by identifying the potential risk factors related to VAP in the neonatal intensive care unit (NICU). The relevant literatures published up to July 2013 were searched in the databases of PubMed, Cochrane Central Register of Controlled Trials, Embase, and Web of Science. Three reviewers screened those literatures and extracted data according to the inclusion and exclusion criteria independently. A total of eight studies including 370 cases and 1,071 controls were identified. Ten risk factors were found to be related to neonatal VAP which were listed as follows in order by odds ratios (ORs): length of stay in NICU (OR 23.45), reintubation (OR 9.18), enteral feeding (OR 5.59), mechanical ventilation (OR 4.04), transfusion (OR 3.32), low birth weight (OR 3.16), premature infants (OR 2.66), parenteral nutrition (OR 2.30), bronchopulmonary dysplasia (OR 2.21), and tracheal intubation (OR 1.12). Conclusion: We identified ten variables as independent risk factors for the development of VAP: length of stay in NICU, reintubation, enteral feeding, mechanical ventilation, transfusion, low birth weight, premature infants, parenteral nutrition, bronchopulmonary dysplasia, and tracheal intubation. Due to several limitations in the present study, further large and well-designed studies are needed to confirm the conclusion.     

新生儿医院感染的调查分析

目的 通过对新生儿医院感染病例进行流行病学调查,探讨其危险因素,分析病原学,为预防和控制医院感染提供依据.方法 对我院新生儿病房2007年1月至2009年12月,医院感染病例的流行病学资料、临床特点、病原学、细菌耐药资料进行回顾性分析和调查.结果 研究期间住院总人数为6347例,发生医院感染433例,感染例次数513例,医院感染率为6.82％,例次感染率8.0％;总住院日73 663 d,日医院感染率6.96‰;呼吸机相关性肺炎发病率为28.7‰;导管相关性血流感染发病率3.5‰.经多元logistic回归分析,结果 显示发生医院感染的主要危险因素是胎龄(OR=1.049)、机械通气(OR=1.810)、脐静脉置管(OR=1.106)、住院时间(OR=1.081)、胎膜早破(OR=1.433).在医院感染疾病构成中,以肺炎最多见,共197例次(38.4％);其中呼吸机相关性肺炎129例次,占肺炎的65.5％,占呼吸机使用人数的24.4％;其次为败血症124例次(24.2％)和腹泻病65例次(12.7％).病原以革兰阴性菌最多见(54.4％),主要为肺炎克雷伯菌(19.6％)、鲍曼不动杆菌(8.1％)、铜绿假单胞菌(7.2％)、嗜麦芽窄食单胞菌(4.8％)和大肠埃希菌(4.8％).肺炎克雷伯菌和大肠埃希菌的产超广谱β-内酰胺酶( ESBLs)率分别达91.4％和75.0％,对头孢菌素普遍耐药;肺炎克雷伯菌、鲍曼不动杆菌、铜绿假单胞菌对亚胺培南的耐药率分别为1.5％、11.1％和41.7％.耐甲氧西林金黄色葡萄球菌和耐甲氧西林凝固酶阴性葡萄球菌的检出率分别为28.6％和95.5％.结论 充分了解新生儿医院感染的危险因素,缩短机械通气和住院时间,尽早拔除中心静脉置管可降低医院感染发病率;革兰阴性菌是最主要的医院感染病原,其中肠杆菌和非发酵菌的多重耐药现象已相当严重.