血流动力学指标对早产儿支气管肺发育不良的预测价值研究

doi:10.12114/j.issn.1007-9572.2021.01.414

摘要/Abstract

摘要： 背景随着我国极早产儿和超早产儿存活率的提高，早产儿支气管肺发育不良（BPD）的发生率也逐年上升，严重影响早产儿生命安全及生存质量。早产儿在发生BPD的过程中存在不同程度血流动力学指标改变，但有关早产儿血流动力学指标与BPD发生的研究相对较少。目的探讨血流动力学指标对早产儿发生BPD的预测价值。方法选取新乡市中心医院2018年9月至2020年12月收治的出生1 h内入院的161例胎龄<32周的早产儿为研究对象。收集早产儿一般资料，包括胎龄、出生体质量、性别、分娩方式；记录早产儿基础疾病及并发症，根据早产儿是否发生BPD将其分为BPD组（n=65）和对照组（n=96）。记录早产儿出生后1 h、12 h、24 h、48 h、72 h、96 h、5 d、6 d、7 d的脉搏灌注指数（PI）；记录早产儿入院后1 h、12 h及24 h的血乳酸值；根据新生儿危重病例评分（NCIS），选择病情危重和极危重的早产儿33例（其中BPD组16例，对照组17例）进行有创动脉血压监测，并记录监测1 h、12 h、24 h的平均动脉压（MAP）。比较两组患儿检查结果，应用受试者工作特征曲线（ROC曲线）评估PI、血乳酸值对早产儿发生BPD的预测价值。结果确诊BPD早产儿共65例，发病率40.3%（65/161）。两组早产儿胎龄、出生体质量、性别、分娩方式比较，差异无统计学意义（P>0.05）；BPD组新生儿窒息、新生儿呼吸窘迫综合征、新生儿肺炎及ROP发生率高于对照组（P<0.05）；两组早产儿败血症、动脉导管未闭、肺出血、脑室内出血、化脓性脑膜炎、贫血发生率比较，差异无统计学意义（P>0.05）。两组早产儿出生后1 h、12 h及24 h的PI比较，差异均有统计学意义（P<0.05）；两组早产儿入院后1 h血乳酸值比较，差异有统计学意义（P<0.05）；两组中病情危重和极危重早产儿不同时段MAP比较，差异无统计学意义（P>0.05）。出生后1 h、12 h、24 h PI预测BPD发生的ROC曲线下面积（AUC）分别为0.847〔95%CI（0.788，0.906），P<0.001〕、0.776〔95%CI（0.705，0.846），P<0.001〕、0.695〔95%CI（0.613，0.778），P<0.001〕；最佳截断值分别为0.55、1.15、1.45；灵敏度分别为76.9%、86.2%、81.5%；特异度分别为75.0%、60.4%、51.0%；入院后1 h血乳酸值预测BPD发生的AUC为0.762〔95%CI（0.686，0.837），P<0.001〕，最佳截断值为6.55，灵敏度为81.5%，特异度为68.7%。结论血流动力学指标PI及乳酸值的改变与早产儿BPD的发生具有相关性，胎龄<32周早产儿出生后24 h内PI对于BPD的预测有一定价值，但仍需进一步研究。

关键词: 支气管肺发育不良, 婴儿, 早产, 血流动力学, 灌注指数, 乳酸, 平均动脉压, 预测

Abstract: Background

In China, the growing prevalence of bronchopulmonary dysplasia (BPD) in increased number of survived very preterm and extremely preterm infants, seriously endangers the life and impairs quality of life in this population. There are different degrees of hemodynamic changes in preterm infants in the process of developing BPD, however, there are relatively few studies about the correlation between the occurrence of BPD and hemodynamic indicators in preterm infant.

Objective

To examine predictive value of the hemodynamic indexes for BPD in premature infants.

Methods

One hundred and sixty-one premature infants (hospitalized within 1 hour of birth, gestational age <32 weeks) were selected from Xinxiang Central Hospital from September 2018 to December 2020. The general data (gestational age, birth weight, sex, and mode of delivery) were collected; the basic diseases and other complications of preterm infants were collected, compared between two groups of infants divided by the prevalence of BPD (n=65) or not (n=96) . PI values (measured at 1, 12, 48, 72 and 96 hours after delivery, and on the 5th, 6th, and 7th days after delivery, respectively) , and serum lactic acid levels (measured at 1, 12, and 24 hours after admission, respectively) were collected. Mean arterial pressure (MAP) levels measured by arterial pressure monitoring at 1, 12 and 24 hours after admission for 33 infants (16 in BPD group and 17 in the control group) with critical or extremely critical conditions suggested by neonatal critical illness score were also collected. Compare the results between two groups, the receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of PI, serum lactic acid and MAP for BPD in preterm infants.

Results

Sixty-five out of the 161 cases 〔40.3% (65/161) 〕were diagnosed with BPD. Preterm infants with and without BPD had no statistically significant differences in gestational age, birth weight, gender, and mode of delivery (P>0.05) . Preterm infants with BPD had higher incidence of neonatal asphyxia, neonatal respiratory distress syndrome, neonatal pneumonia, and retinopathy of prematurity than those without (P<0.05) . Preterm infants with and without BPD had no statistically significant differences in sepsis, pulmonary hemorrhage, PDA, IVH, purulent meningitis and anemia (P>0.05) . PI values at 1, 12 and 24 hours after birth differed significantly between the two groups (P<0.05) . Serum lactic acid at 1 hour after admission differed significant between the two groups (P<0.05) . MAP levels at different time periods showed no significant differences between critical and extremely critical preterm infants with and without BPD (P>0.05) . In predicting BPD, the PI at 1-hour, 12-hour, and 24-hour was 0.847〔95%CI (0.788, 0.906) , P<0.001〕, 0.776〔95%CI (0.705, 0.846) , P<0.001〕, 0.695〔95%CI (0.613, 0.778) , P<0.001〕, respectively; the optimal cutoff value was chosen as 0.55, 1.15, 1.45, with the sensitivity of 76.9%, 86.2%, 81.5% and the specificity of 75.0%, 60.4%, 51.0%; serum lactic acid at 1 hour after birthhad an AUC of 0.762〔95%CI (0.686, 0.837) , P<0.001〕, the optimal cutoff value was chosen as 6.55, with the sensitivity of 81.5%, and the specificity of 68.7%.

Conclusion

In preterm infants with a gestational age <32 weeks, the change of hemodynamic indicatou PI and lactic acid value maybe correlated with the occurrence of BPD. PI value within 24 hours after birth may be an earlypredictor for BPD, but further research is still needed.

Key words: Bronchopulmonary dysplasia, Infant, remature, Hemodynamics, Perfusion index, Lactic acid, Mean arterial pressure, Forecasting

中图分类号:

R563.9

贾楠,贺玉娟,赵晓晓,等. 血流动力学指标对早产儿支气管肺发育不良的预测价值研究[J]. 中国全科医学, 2022, 25(08): 963-968. DOI: 10.12114/j.issn.1007-9572.2021.01.414.

JIA Nan, HE Yujuan, ZHAO Xiaoxiao, ZHANG Weixing.

Predictive Value of Hemodynamic Indicators for Bronchopulmonary Dysplasia in Preterm Infants [J]. Chinese General Practice, 2022, 25(08): 963-968.

图/表 6

参考文献 22

[1]	ENDO T, SAMPEI M, FUKUDA S. Kangaroo mother care alters chromogranin A and perfusion index in preterm babies[J]. Pediatr Int，2021，63(1):53-59. DOI：10.1111/ped.14350.
[2]	PLANA M N, ZAMORA J, SURESH G，et al. Pulse oximetry screening for critical congenital heart defects[J]. Cochrane Database Syst Rev，2018，3:CD011912. DOI：10.1002/14651858.CD011912.pub2.
[3]	易琳，杨传忠，李欢，等. 灌注指数以及灌注变异指数在早产儿动脉导管未闭中的应用[J]. 中国医学创新，2019，16(13):134-136. DOI：10.3969/j.issn.1674-4985.2019.13.034.
[4]	邵肖梅，叶鸿瑁，丘小汕. 实用新生儿学[M]. 5版. 北京：人民卫生出版社，2019:727-732. 0-347.
[5]	魏克伦，陈克正，孙眉月，等. 新生儿危重病例评分法（草案）[J]. 中华儿科杂志，2001，39(1):42-43. DOI：10.3760/j.issn:0578-1310.2001.01.013.
[6]	ECKERT G U, FORTES FILHO J B, MAIA M，et al. A predictive score for retinopathy of prematurity in very low birth weight preterm infants[J]. Eye（Lond），2012，26(3):400-406. DOI：10.1038/eye.2011.334.
[7]	STEURER M A, NAWAYTOU H, GUSLITS E，et al. Mortality in infants with bronchopulmonary dysplasia：data from cardiac catheterization[J]. Pediatr Pulmonol，2019，54(6):804-813. DOI：10.1002/ppul.24297.
[8]	FINE-GOULDEN M R, DURWARD A. How to use lactate[J]. Arch Dis Child Educ Pract Ed，2014，99(1):17-22. DOI：10.1136/archdischild-2013-304338.
[9]	费菲，王仲.《急性循环衰竭中国急诊临床实践专家共识》解读——病理生理、早期识别与诊断部分[J]. 中国医药科学，2016，6(9):1-5.
[10]	LIMA A, BAKKER J. Noninvasive monitoring of peripheral perfusion[J]. Intensive Care Med，2005，31(10):1316-1326. DOI：10.1007/s00134-005-2790-2.
[11]	DE FELICE C, DEL VECCHIO A, CRISCUOLO M，et al. Early postnatal changes in the perfusion index in term newborns with subclinical chorioamnionitis[J]. Arch Dis Child Fetal Neonatal Ed，2005，90(5):F411-414. DOI：10.1136/adc.2004.068882.
[12]	JEGATHEESAN P, SONG D L, ANGELL C，et al. Oxygen saturation nomogram in newborns screened for critical congenital heart disease[J]. Pediatrics，2013，131(6):e1803-1810. DOI：10.1542/peds.2012-3320.
[13]	CHOUDHARY V K, RASTOGI B, SINGH V P，et al. Comparison of hemodynamic responses along with perfusion index to tracheal intubation with Macintosh and McCoy laryngoscopes[J]. Int J Res Med Sci，2018，6(5):1673. DOI：10.18203/2320-6012.ijrms20181757.
[14]	KROESE J K, VAN VONDEREN J J, NARAYEN I C，et al. The perfusion index of healthy term infants during transition at birth[J]. Eur J Pediatr，2016，175(4):475-479. DOI：10.1007/s00431-015-2650-1.
[15]	ALDERLIESTEN T, LEMMERS P M, BAERTS W，et al. Perfusion index in preterm infants during the first 3 days of life：reference values and relation with clinical variables[J]. Neonatology，2015，107(4):258-265. DOI：10.1159/000370192.
[16]	CORSINI I, CECCHI A, COVIELLO C，et al. Perfusion index and left ventricular output correlation in healthy term infants[J]. Eur J Pediatr，2017，176(8):1013-1018. DOI：10.1007/s00431-017-2920-1.
[17]	TUTEN A, DINCER E, TOPCUOGLU S，et al. Serum lactate levels and perfusion index：are these prognostic factors on mortality and morbidity in very low-birth weight infants？[J]. J Matern Fetal Neonatal Med，2017，30(9):1092-1095. DOI：10.1080/14767058.2016.1205019.
[18]	章斌，雷小平，康兰，等. 无创心输出量测量仪在早产儿支气管肺发育不良早期预测中的价值研究[J]. 重庆医学，2020，49(23):3884-3888. DOI：10.3969/j.issn.1671-8348.2020.23.005.
[19]	ALLEN M. Lactate and acid base as a hemodynamic monitor and markers of cellular perfusion[J]. Pediatr Crit Care Med，2011，12(4 ):S43-49. DOI：10.1097/PCC.0b013e3182211aed.
[20]	HATHERILL M, WAGGIE Z, PURVES L，et al. Mortality and the nature of metabolic acidosis in children with shock[J]. Intensive Care Med，2003，29(2):286-291. DOI：10.1007/s00134-002-1585-y.
[21]	PORYO M, WISSING A, ZEMLIN M，et al. Nucleated red blood cells and serum lactate values on days 2 and 5 are associated with mortality and morbidity in VLBW infants[J]. Wien Med Wochenschr，2019，169(3/4):87-92. DOI：10.1007/s10354-018-0649-8.
[22]	HARIRI G, JOFFRE J, LEBLANC G，et al. Narrative review：clinical assessment of peripheral tissue perfusion in septic shock[J]. Ann Intensive Care，2019，9(1):37. DOI：10.1186/s13613-019-0511-1.

组别	例数	胎龄（±s，周）	出生体质量（±s，kg）	性别（男/女）	分娩方式（顺/剖）
对照组	96	29.5±1.4	1.27±0.19	49/47	51/45
BPD组	65	29.0±1.5	1.23±0.21	29/36	29/36
χ²（t）值		-1.833^a	-1.334^a	0.063	0.083
P值		0.069	0.184	0.423	0.289

组别	例数	胎龄（±s，周）	出生体质量（±s，kg）	性别（男/女）	分娩方式（顺/剖）
对照组	96	29.5±1.4	1.27±0.19	49/47	51/45
BPD组	65	29.0±1.5	1.23±0.21	29/36	29/36
χ²（t）值		-1.833^a	-1.334^a	0.063	0.083
P值		0.069	0.184	0.423	0.289

组别	例数	基础疾病				并发症
组别	例数	NRDS	新生儿肺炎	新生儿败血症	PDA	新生儿窒息	肺出血	IVH	化脓性脑膜炎	贫血	ROP
对照组	96	57（59.4）	61（63.5）	68（70.8）	55（57.3）	22（22.9）	3（3.1）	13（13.5）	5（5.3）	72（75.2）	23（24.0）
BPD组	65	51（78.5）	62（95.4）	53（81.5）	40（61.5）	38（58.5）	6（9.2）	4（6.2）	6（9.2）	49（75.4）	33（50.8）
χ²值		6.394	21.795	2.379	0.289	20.946	2.738	2.240	0.949	0.004	12.282
P值		0.009	<0.001	0.123	0.519	<0.001	0.098	0.134	0.330	0.956	<0.001

组别	例数	基础疾病				并发症
组别	例数	NRDS	新生儿肺炎	新生儿败血症	PDA	新生儿窒息	肺出血	IVH	化脓性脑膜炎	贫血	ROP
对照组	96	57（59.4）	61（63.5）	68（70.8）	55（57.3）	22（22.9）	3（3.1）	13（13.5）	5（5.3）	72（75.2）	23（24.0）
BPD组	65	51（78.5）	62（95.4）	53（81.5）	40（61.5）	38（58.5）	6（9.2）	4（6.2）	6（9.2）	49（75.4）	33（50.8）
χ²值		6.394	21.795	2.379	0.289	20.946	2.738	2.240	0.949	0.004	12.282
P值		0.009	<0.001	0.123	0.519	<0.001	0.098	0.134	0.330	0.956	<0.001

组别	例数	出生后1 h	出生后12 h	出生后24 h	出生后48 h	出生后72 h	出生后96 h	出生后5 d	出生后6 d	出生后7 d
对照组	96	0.69±0.21	1.23±0.27	1.41±0.24	1.66±0.27	1.93±0.32	2.21±0.30	2.39±0.32	2.36±0.32	2.38±0.33
BPD组	65	0.41±0.17	0.96±0.20	1.22±0.27	1.62±0.27	1.87±0.31	2.24±0.28	2.31±0.28	2.30±0.26	2.31±0.27
t值		-9.036	-6.980	-4.569	-0.929	-1.326	0.511	-1.669	-1.144	-1.435
P值		<0.001	<0.001	<0.001	0.354	0.187	0.610	0.097	0.254	0.153