article: Clinical characteristics and management of congenital chylothorax refractory to conservative treatment: a retrospective study of 11 cases from a single center - Minerva Medica 2022 Oct 18 - Minerva Medica - Journals

目的:分析影响新生儿化脓性脑膜炎获得性感染的家庭护理中的高危因素,以期为新生儿期的预防保健、减少新生儿化脓性脑膜炎的发病率提供指导依据.方法:选取收治的新生儿化脓性脑膜炎患儿家长进行问卷调查,问卷内容主要涉及家庭护理方面因素的调查,包括看护者情况、家庭经济居住情况、护理卫生、喂养方面、家属患病情况等.调查由专人负责,遵循纳入标准与排除标准现场进行问卷调查并收回.结果:一共对115例新生儿化脓性脑膜炎患儿的家长进行了问卷调查,其中得到完整问卷结果的共83例(72.2％).83例患儿均为足月儿,其中男49例,女34例.原发感染灶分析:19例(22.9％)存在脐部感染、呼吸道感染26例(31.3％)、泌尿道感染14例(16.9％)、消化道感染10例(12.0％)、皮肤感染5例(6.0％)、感染灶不明确病例9例(10.8％).发现脐部没有消毒或消毒不规范、奶瓶消毒不规范、哺乳前手卫生不规范、看护者患病、母亲严重乳腺炎继续哺乳等均为导致新生儿感染而引起化脓性脑膜炎的高危因素;并且多数家庭具有2种或2种以上高危因素并存.结论:有效的防控可避免新生儿患严重感染性疾病,指导患儿家长或看护者进行合理正确的护理及对新生儿常见问题、多发疾病的宣教尤为重要,开展社区母婴卫生知识讲座及普及新生儿护理规范指导非常关键.

目的 探讨本科生新生儿护理临床见习线上教学的实践效果.方法 在儿科护理学中的新生儿护理临床见习采用线上教学的形式.新生儿护理临床技能训练(2个学时),应用教学视频进行示教,要求学生拍摄反示教视频并提交,教师组织线上讨论对反示教视频进行点评.新生儿护理临床思维训练(4个学时)采用案例教学、虚拟仿真操作系统练习、问题讨论与反思3种形式进行,其中案例教学包括综合性案例分析和进展性案例分析.教学后,调查学习该课程的大学三年级的92名护理本科生对教学效果的评价.结果 学生推荐进展性案例分析(92％)、综合性案例分析(90％)等教学方式,认为此次线上教学有提高综合运用知识能力(95％)、提高人文素养(91％)、增强临床思维和决策能力(87％)的作用.结论 新生儿护理临床见习线上教学效果较好,以进展性案例分析培养学生的临床思维、以虚拟仿真系统练习培养学生的临床判断和决策能力可作为传统线下见习教学的有益补充.

Objective:To explore the clinical characteristics and treatment strategies of refractory congenital chylothorax (CC) in neonates.Methods:Eleven neonates with refractory CC who were hospitalized in Children′s Hospital, Capital Institute of Pediatrics from June 2015 to December 2019 were selected as research subjects. The clinical manifestations, ancillary tests, treatment strategies, regression and follow-up were retrospectively analyzed. The procedures followed in this study were in accordance with the World Medical Association Declaration of Helsinki revised in 2013, and informed consent for clinical study was signed with the guardians of neonates.Results:①Among the 11 cases of refractory CC, 8 were term infants and 3 were preterm infants, with gestational age ranging from 31 to 40 weeks; 6 were boys and 5 were girls; 4 received prenatal diagnosis and 3 were combined with fetal edema. ② Seven cases developed within 10 min after birth, 11 cases showed tachypnea, weakening of respiratory sound in affected lung, chest X-ray, chest CT or chest ultrasonography all suggested pleural effusion, including 7 cases of bilateral pleural effusion and 4 cases of unilateral pleural effusion (left side), and the pleural effusion test showed celiac fluid. ③ After failure of 2-4 weeks of conservative treatment (dietary modification, respiratory support, thoracic close drainage, octreotide, anti-infective therapy, etc.), 10 cases were treated with chemical pleural fixation (intra-thoracic injection of erythromycin), of which 7 cases were treated with octreotide during the same time, and the number of erythromycin intrathoracic injections was 3-7 for those who did not combine with octreotide. During intrapleural injection of erythromycin, 4 children showed tachycardia and irritability, and 1 patient showed significantly increased blood glucose (18.8 mmol/L). Two cases underwent thoracoscopic exploration and repair of chylous fistula. ④After treatment, 11 cases of refractory CC were absorbed and improved, and the total length of hospital stay was 40-73 days. Among them, 1 case died after automatic discharge, and 1 case was lost to follow-up because of suspected parents of tracheoesophageal fistula. No recurrence occurred after discharge.Conclusions:Refractory CC is common in full-term children. For children who have failed in early dietary regulation, intravenous nutrition, thoracic close drainage and octreotide intravenous infusion for 2-4 weeks, chemical pleural fixation (intrathoracic injection of erythromycin) can be combined. For patients with ineffective treatment for more than 4 weeks, thoracoscopic exploration can be used to repair lymphatic fistula after identifying the leak in order to improve the cure rate of refractory CC.

中心静脉置管(central venous catheterization,CVC)技术在重症领域已经得到了日趋广泛的应用,是危重新生儿,尤其是极低出生体重儿、超低出生体重儿静脉开放的最佳途径,其具有安全、可靠、耐高渗的特点,既减少了对患儿的过度刺激,又保证了静脉营养的供给,尤其适用于早产儿长期静脉营养治疗.但中心静脉置管的并发症在新生儿和小婴儿中也要明显高于成人[1-2],常见的并发症有静脉炎、感染、导管脱出、导管堵塞、血栓形成等[3-4].但也有文献报道一些罕见或严重的并发症,如心包填塞、动静脉瘘、神经损伤、呼吸窘迫等[5].在一项587例新生儿和婴儿的研究中,导管相关并发症的发生率为28%,并且有2例死亡病例是由心脏填塞引起;22%的导管发生了机械性并发症,包括移位(11. 6%)、体外穿孔(5. 3%)和导管堵塞(5.1%);4%的导管发生了感染性并发症,包括确诊的菌血症、穿刺部位的脓肿和孤立性的发热;1%的导管发生了腔静脉血栓形成,体重小于2 500 g和近心端置管均与更高的并发症发生率相关[6].CVC液体渗出导致多浆膜腔积液(胸腔积液、腹腔积液及心包积液)的病例未曾见报道,是 CVC的严重并发症之一.首都儿科研究所附属儿童医院新生儿内科于2017年1月发生1例经锁骨下中心静脉置管并发新生儿多浆膜腔积液的危重病例,经积极抢救与护理治愈出院,现报道如下.