新生儿重症监护室新生儿尤其早产儿因为发育不成熟,免疫力低下,再加上PICC等侵入性诊疗措施多,广谱抗生素使用等因素并存,真菌感染发生率明显高于普通病房。真菌感染缺乏特异的临床表现,早期诊断困难,病死率、致残率高。本文就NICU新生儿PICC相关的真菌感染现状、发病机制、诊断、预防及治疗做一综述。
The incidence of fungal infection in neonatal intensive care unit is significantly higher than that in general wards due to immature development of neonates, especially premature infants, low im-munity, more invasive diagnosis and treatment measures such as PICC and the use of broad-spectrum antibiotics. Fungal infection lacks specific clinical manifestations, early diagnosis is difficult, and mortality and disability are high. This article reviews the status about pathogenesis, diagnosis, prevention and treatment of PICC related fungal infections in NICU neonates.
新生儿重症监护室,经外周静脉穿刺中心静脉置管,真菌感染, Neonatal Intensive Care Unit Peripherally Inserted Central Catheter Fungal InfectionNICU新生儿PICC相关的真菌感染诊治进展
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1. 引言
新生儿重症监护室(neonatal intensive care unit, NICU)因广谱抗生素的广泛使用,且各种侵入性诊疗措施较多,真菌感染发生率明显高于普通病房。真菌感染已成为NICU院内感染的第3位常见原因,极低出生体重儿真菌感染的发病率为1.6%~9%,而超低出生体重儿则高达10%~16%,死亡率约20%~60% [1] [2],其中念珠菌最常见 [3] [4] [5],国内研究也显示非白念珠菌为新生儿真菌感染的主要致病菌 [6] 。NICU为便于各种药物及肠外营养的输注,多需要经外周静脉穿刺中心静脉置管(peripherally inserted central catheter, PICC),因此真菌已成为PICC相关性感染的主要致病菌之一。尤其早产儿PICC使用率更高,真菌感染概率更高,且早产儿真菌感染后临床表现多数不典型,早期诊断困难,病死率、致残率高。本文就NICU新生儿PICC相关的真菌感染诊治进展做一综述。
2. 新生儿导管相关性真菌感染的现状
在新生儿中,极低、超低出生体重儿国内曾报道死亡率介于63%~74%之间 [7],胎龄越小、体重越低,死亡率越高。早产儿,尤其是极低、超低体重儿需要长期肠外营养治疗,且静脉营养液往往需24 h持续输注,由于所使用的药物pH值和静脉营养液高渗透性会导致外周静脉出现液体渗出、化学性静脉炎、药液渗漏等并发症而拔管,外周静脉管保留时间多数在2~3天。PICC是从外周静脉穿刺,通过引导针将标有刻度的导管插入并使其顶端位于上腔或下腔静脉内的中心静脉导管置入术。低、极低、超低体重儿反复静脉穿刺难度大,通过PICC置管避免了反复穿刺及药液渗漏对患儿造成的不良后果。在NICU内,PICC主要用于需中长期肠外营养支持,以及应用高渗液体、刺激性药物的患儿。而PICC由于输出口在中心静脉,可长时间留置,避免多次浅静脉穿刺,减少对患儿疼痛刺激,减少局部渗出等;经PICC可输注较高渗透压的营养液,机体能量摄入明显高于经外周静脉途径,患儿生理体重下降持续时间短于外周静脉途径,恢复到出生体重时间缩短,后期体重增长也快于外周静脉营养途径。随着现代围生医学的发展,PICC使用越来越广泛,已成为早产儿尤其是极低、超低出生体重儿的生命通道。但同时导管相关性感染(catheter related infection,CRI)发生率也明显升高,是PICC最严重的并发症。CRI的发生即延长了住院天数,增加了患儿的痛苦,又导致患儿生存质量下降,预后不佳。
病因预防:由于新生儿免疫力低下,尤其对于已使用PICC的早产儿,NICU应遵守医院内感染管理规定,强化医务人员无菌操作观念,保持环境清洁,尽可能避免过多的侵入性检查治疗,减少真菌感染高危因素。首先,建立严格的导管使用准入制度,制定统一的操作流程和操作标准,建立严格的人员培训制度,不断提高医务人员置管技术水平。严格掌握留置血管内导管的适应证。置管操作前严格按六步法洗手。做好穿刺前准备是预防术后发生血流感染的重要方法,穿刺护士应严格执行各种无菌操作,戴帽子、口罩,戴无菌手套,按照要求准备各项消毒器械,采用安尔碘进行皮肤消毒,消毒范围应为10 cm × 10 cm,铺无菌巾、洞巾等方法形成一个无菌区。尽量单次短时间内完成穿刺,减少暴露时间,提高一次性穿刺成功率,降低反复穿刺所致的感染等并发症。其次,保持环境清洁,包括穿刺前应对室内空气进行消毒,增加室内通风,每日需更换新生儿蓝光箱和新生儿暖箱湿化液,加强新生儿暖箱消毒。最后,应尽量缩短机械通气时间,尽早开使肠内营养,严格掌握抗生素适应症,避免长时间使用H2受体拮抗剂等。总之,应从多方面采取有效措施降低新生儿真菌感染的发生率。
熊星宇,李杨方. NICU新生儿PICC相关的真菌感染诊治进展The Progress of Diagnosis and Treatment about PICC Related Fungal Infections in NICU Neonates[J]. 临床医学进展, 2018, 08(10): 875-881. https://doi.org/10.12677/ACM.2018.810146
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