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中国循证儿科杂志

中国循证儿科杂志 ›› 2022, Vol. 17 ›› Issue (1): 1-9.

• 论著 •    下一篇

基于中国新生儿协作网的极早产儿中心血管导管使用情况的横断面调查

叶旭强1，顾昕玥2a，王延辰2a，杨童玲2b，胡晓静2c，曹云2a，2b，周文浩2a，2b，Shoo K Lee3，
戴怡蘅1，蒋思远2a，2b


  

  1. 1 南方医科大学附属佛山妇幼保健院新生儿科佛山，528000 ；2 复旦大学附属儿科医院上海，201102，a 国家卫生健康委员会新生儿疾病重点实验室（复旦大学），b 新生儿科 ，c 护理部；3 加拿大西奈山医院母婴健康研究中心加拿大多伦多，M5G 1X5
  • 收稿日期:2022-03-05 修回日期:2022-03-05 出版日期:2022-02-25 发布日期:2022-02-25
  • 通讯作者: 戴怡蘅，蒋思远

Use of central vascular catheters among very preterm infants in Chinese NICUs: A multicenter crosssectional study

YE Xuqiang1, GU Xinyue2a, WANG Yanchen2a, YANG Tongling2b, HU Xiaojing2c, CAO Yun2a, 2b, ZHOU Wenhao2a, 2b, Shoo K LEE3, DAI Yiheng1, JIANG Siyuan2a, 2b   

  1. 1 Division of Neonatology, Foshan Women and Children's Hospital Affiliated to Southern Medical University, Foshan 528000, China; 2 Children's Hospital of Fudan University, Shanghai 201102, China, a NHC Key Laboratory of Neonatal Diseases (Fudan University), b Division of Neonatology, c Nursing Department; 3 The Maternal Infant Care Research Center (MiCARE), Mount Sinai Hospital, Toronto, Canada, M5G 1X5
  • Received:2022-03-05 Revised:2022-03-05 Online:2022-02-25 Published:2022-02-25
  • Contact: DAI Yiheng, email：daiyiheng@163.com; JIANG Siyuan, email：jiangsiyuan@fudan.edu.cn

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摘要： 背景：近年来中国极早产儿救治数量显著增加，中心血管导管已成为国内NICU的常用技术，极早产儿救治中可能存在中心血管导管的不合理使用，但目前尚缺乏其使用现况数据。 目的：通过回顾采集和分析中国新生儿协作网（CHNN）数据库正式运行第1年极早产儿中心血管置管现况，并对各医院进行问卷调查，以期发现当前极早产儿中心血管导管使用中存在的问题，为后续质量改进提供基线数据。 设计：横断面调查。 方法：基于2019年CHNN成员医院登记的极早产儿中心血管导管数据，描述不同出生胎龄早产儿中心血管导管使用状况（置管率、留置时间），问卷调查CHNN成员医院中心血管导管病房规范及管理、置管指征、拔除指征、维护实践和并发症情况。纳入CHNN数据库中入院日期在2019年1月1日至2019年12月31日、生后24 h内收入NICU、出生胎龄24+0~31+6周的极早产儿连续病例；排除存在严重先天性畸形者，治疗未结束时转至非CHNN医院者，未达到医生建议的出院标准家长主动选择终止维持生命支持的治疗并出院者；剔除病例纳入不完整或数据质量不合格的成员医院的数据。根据胎龄分为24~28周和~31周亚组。根据医院类型分为儿童专科医院、妇幼保健院和综合医院。自行设计问卷，调查病房规范及管理、留置及拔除指征、中心血管导管维护、中心血管导管相关并发症现况，由NICU主任或经主任授权的高年资新生儿专科医生填写问卷。 主要结局指标：中心血管导管置管类型、置管率和留置时间。 结果：①CHNN成员57家三级医院NICU 6 532例极早产儿进入本文分析，留置中心血管导管4 563例（69.9%），其中脐动脉导管（UAC）368例（5.6%）、脐静脉导管（UVC）2 532例（38.8%）、经外周穿刺中心静脉置管（PICC）3 895例（59.6%）和外科中心静脉置管（SCVC）55例（0.8%）。相对于未留置中心血管导管患儿，留置中心血管导管患儿的胎龄小、出生体重低、小于胎龄儿比例高、多胎比例高、本院出生比例低及5 min Apgar评分＜7分比例高（P均<0.01），同时其母亲妊娠高血压、产前激素使用以及剖宫产比例均较高（P均<0.01）。留置与未留置中心血管导管极早产儿相比，病死率差异无统计学意义，但各项并发症更多，住院时间更长，差异有统计学意义。②任意中心血管导管置管率总体呈现随胎龄增加而下降的趋势，胎龄24~28周亚组和~31周亚组中心血管导管置管率分别为87.8%和63.1%。UAC和UVC置管率随胎龄增加而下降。PICC置管率随胎龄呈哑铃状，胎龄25~28周置管率最高（75.2%~85.5%），但仍有52.8%的胎龄~31周亚组患儿留置。留置≥2类中心静脉置管（UVC以及PICC或SCVC）占29.0%，随胎龄增加而下降，胎龄~31周亚组占21.8%。③UAC、UVC和PICC中位留置时间分别为6（4~8）d、7（4~9）d和22（15~31）d。不同类型医院CHNN成员医院中心血管导管置管率及留置时间差别显著。④共发放问卷57份，回收52份（91.2%），50% CHNN成员医院对中心血管导管管理有病房规范文件。在各类导管的留置指征、拔除指征、最长留置天数上存在单位间差异。62%和23%的CHNN成员医院在近1年内发生过中心血管导管相关的渗漏和血栓并发症。 结论：国内NICU中极早产儿中心血管导管留置较为普及，存在过度置管和置管不足共存、PICC置管时间过长、CHNN成员医院差异大等主要问题。亟需建立统一指南和规范，并通过质量控制和质量改进，促进更加合理、规范的中心血管导管使用。

关键词: 极早产儿, 脐动脉导管, 脐静脉导管, 经外周中心静脉置管, 中心静脉置管, 置管时间

Abstract: Background：With an increasing number of very preterm infants (VPI, <32 weeks' gestation) treated in China, central vascular catheterization has become a common technique in Chinese neonatal intensive care units (NICUs). Inappropriate use of central vascular catheters(CVCs) may occur in the treatment, but there is still lack of relative data. Objective：To retrospectively analyze the firstyear data from the standardized database of the Chinese Neonatal Network (CHNN) and preform hospitallevel questionnaires, to reveal the current problem of central vascular catheterization among VPIs in Chinese NICUs and to provide baseline data for future quality improvement program. Design：Crosssectional study. Methods：The study described the current situation of central catheterization across gestational age (GA) weeks, including rate, duration and site variation, using the firstyear data of CHNN (from Jan. 1st 2019 to Dec. 31st 2019) from the participating NICUs. Questionnaires were collected on hospital level in terms of the regulation and management of CVC wards, indications of insertion and removal, and related complications of central catheterization. Infants with GA of 24+0~31+6 weeks, admitted into CHNN database from Jan. 1st 2019 to Dec. 31st 2019 within 24 hours after birth were included. Those infants with major congenital anomalies, transferred to other hospitals or discharge against medical advice were excluded. Incomplete and substandard data were also excluded. Subgroup analysis were done for infants with GA at 2428 weeks and 2931 weeks. Research sites were classified into children's specialized hospitals, maternal and children's healthcare centers and general hospitals. Questionnaires were designed to investigate the regulation, management, indications, maintenance and related complications of central catheterization, which were filled by department directors or senior neonatologists authorized by the director. Main outcome measures：The type, rate and duration of central catheterization. Results：A total of 6,532 VPIs from 57 CHNN participating sites were included in the analysis. A total of 69.9% (4,563/6,532) cases received central catheterization. Overall, 38.8% (2,532/6,532), 5.6% (368/6,532), 59.6% (3,895/6,532) and 0.8% (55/6,532)infants received umbilical venous catheters(UVC), umbilical artery catheters(UAC), peripherally inserted central catheters(PICC) and surgical central venous catheters(SCVC). Infants with central catheterization had smaller GA and lower birthweight, and were more likely to be smallforGA, multiple birth, outborn and with 5min Apgar score less than 7, compared to noncatheterized infants (P <0.01). The proportion of pregnancy hypertension, antenatal hormone use, and cesarean section was also higher in the mothers of catheterized infants. The mortality rate did not differ between catheterized and noncatheterized infants but catheterized infants had higher rate of each morbidity and longer hospitalization (P <0.01). Rate of any type of central catheterization generally decreased along with the increasing GA, and the rates were 87.8% and 63.1% for 2428 GA weeks and 2931 GA weeks respectively. Rates of UAC and UVC also decreased along with the increasing GA. Rate of PICC was the highest at 2528 GA weeks, and it was still as high as 52.8% for infants at 2931 GA weeks. The rate of using two or more catheters(UVC/PICC/SCVC) was 29% at 2528 GA weeks, which decreased to 21.8% at 2931 GA weeks. The median duration of UAC, UVC and PICC were 6.0 (IQR: 4.08.0) days, 7.0 (IQR: 4.09.0) days and 22 (IQR: 15.031.0)days, respectively. There were significant variations among NICUs with different hospital types on the catheterization rates and the duration. Response rate of the questionnaire was 91.2% (52/57). Only 50% (26/52) hospitals have hospital guidelines for central vascular catheterization. There were also significant variations on the indications of insertion and removal, and the longest duration as well. A total of 62% (32/52) hospitals had central linerelated leakage and 23% (12/52) had thrombosis within one year. Conclusion：Central vascular catheterization has been commonly used in Chinese NICUs. However, overuse and insufficiency are both existing. Other major problems are the exceeding length of PICC and significant site variation. Guidelines and regulations are on demand. National quality improvement efforts are needed to promote the rationale and standardized use of central catheters for VPIs in NICUs.

Key words: Very preterm infants, Umbilical artery catheter, Umbilical venous catheter, PICC, Central venous cannulation, Duration of catheterization