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。

A national multicenter cross-sectional survey of iatrogenic skin injury in neonates in NICU

Background：Iatrogenic skin injury is a common problem in neonates admitted to NICU. Objective：To investigate the incidence of neonatal iatrogenic skin injury in NICUs in China. Design：Cross-sectional survey. Methods：Children's Hospital of Fudan University took the lead in establishing the NICU clinical data database of neonatal iatrogenic skin injury, which included 22 tertiary hospitals in 15 provinces, autonomous regions and municipalities directly under the central government. The causes of iatrogenic skin injury were related to diapers, viscose, pressure (including medical devices), surgery, vascular access, and physical or chemical factors. The continuous cases reported by NICUs of the cooperative hospitals were sent to the database, and the data were from the electronic medical record system or paper medical document records. The reported data included demographic data, medical devices use, iatrogenic skin injury events, the age, weight and length of hospital stay of the infant at the time of each iatrogenic skin injury, the location, size, type, color, treatment measures and prognosis of skin injury. The leading hospital trained the cooperating hospitals according to the indicators in the database and started data collection after passing the examination. The leading hospital was responsible for reviewing the data. Main outcome measures：Incidence of iatrogenic skin injury in NICU hospitalized neonates. Results：From December 1, 2019 to January 31, 2020, the data of NICU consecutive cases (n=8,126) collected by 22 cooperative hospitals were all qualified and included in this analysis. There were 521 cases of iatrogenic skin injury (6.4%), and the incidence of iatrogenic skin injury in NICU in children's specialized hospitals, general hospitals and maternal and child health hospitals were 7.4%(280/3,783), 6.4% (153/2,387) and 4.5%(88/1,956), respectively. There were 566 times of iatrogenic skin injury in 521 neonates, and 45 cases (8.6%) had two times of iatrogenic skin injury. The median age of neonates with iatrogenic skin injury was 6 (3, 17) days, those within 1 week after birth accounting for 57.4%(n=299). The median corrected gestational age of neonates with iatrogenic skin injury was 37.2% (32.7, 40.0) weeks, those with the corrected gestational age≥40 weeks accounting for 57.4%(n=294). The median weight of neonates with iatrogenic skin injury was 2,800 (1,912 3,450) g, those with the weight≥2,500 g accounting for 59.1%(n=308). There were 250 cases of diaper related skin injury (48.0%), 81 cases of pressure related (including medical device related) (15.5%), 69 cases of viscose related (13.2%), 70 cases of various physical and chemical factors related (13.4%), 22 cases of vascular access related (4.2%), 14 cases of surgery related (2.7%), and 15 cases of other types (2.9%). The proportion of all kinds of iatrogenic skin injury in neonates aged 1 7 days was the highest. Except that pressure related skin injury was easy to occur in very low birth weight infants and iatrogenic viscose related skin injury was easy to occur in all body recombination, other types of skin injury mostly occurred in neonates weighing≥2,500 g. Pressure-related and viscose-related skin injuries mostly occurred in neonates with the corrected gestational age of 28-32 weeks. Vascular access-related skin injuries accounted for a relatively even proportion in each corrected gestational age group, and other skin injuries were more likely to occur in neonates with the corrected gestational age >32 weeks. Most iatrogenic skin injuries(78.9%) occurred within one-week hospitalization stay of <1 week. The incidence rate decreased week by week. Conclusion：The incidence of iatrogenic skin injury in NICU neonates in China was 6.4%. Diaper-related dermatitis, the application of medical devices, and the use of medical tape were the three main factors of iatrogenic skin injury in neonates. Iatrogenic skin injury was affected by many factors, such as gestational age, birth weight, and the use of various catheters.