組合式護理照護對降低早產兒腦室內出血之成效探討

Abstract

研究背景與目的：腦室內出血為早產兒嚴重併發症之一，出生體重低於1500g之早產兒約25-30％的發生率，與長期神經系統後遺症和死亡率有關。現行預防腦室內出血的方法中，除了預防早產、產前給予皮質類固醇藥物、積極治療絨毛膜炎、改善產後早產兒復甦與輸送流程外，許多國外研究顯示護理介入措施能降低腦室內出血與死亡風險，然而並無一致的做法，且國內尚無此類研究的論述及數據。故本研究目的為探討組合式護理照護措施對預防早產兒腦室內出血之成效。 研究方法：採類實驗研究設計，於北部某醫學中心新生兒加護病房納入妊娠週數≦30週或體重≦1500g之早產兒。控制組透過醫院資料庫回溯電子病例檔（retrospective cohort）選取2017年01月01日至2019年12月31日符合收案條件之早產兒並串聯母親檔案。實驗組以前瞻性研究方式收案，除病房常規照護外，從早產兒出生入加護病房至第三天施行組合式護理措施。介入措施之成效評估包含出生第三天與第七天腦室出血發生率、死亡率及加護病房住院天數。研究資料以SPSS 26版軟體建檔及分析，並以羅吉斯回歸(Logistic regression)及多元迴歸分析(Multiple regression analysis)控制實驗組與對照組間具異質性的自變項之下，分析本研究之介入措施的成效。 研究結果：本研究共納入178位早產兒，實驗組30位，控制組148位。早產兒平均出生週數28.6 ± 2.1週、出生體重1071 ± 354.9g，男嬰比例稍高(51.7％)，母親平均年齡36.1歲(SD: 4.5)，此胎為單胞胎(65.2％)者佔多數。實驗組與控制組早產兒的基本屬性、醫療問題及接受過的治療項目大多具同質性，唯出生週數、妊娠週數百分位、是否輸注過凝血相關血品及3天內是否有症狀的開放性動脈導管等統計上達顯著差異；在母親的基本資料方面只有年齡有統計上的顯著差異(實驗組38.0歲；控制組35.7歲，p=0.01)。結果方面，實驗組第三天腦室內2度以上出血的發生率6.7％、第七天腦室內2以上出血發生率10％、死比率0％、住院天數81.9(SD：73.6)天。控制組第三天腦室內2度以上出血發生率8.8％、第七天腦室內2度以上出血發生率8.8 ％、死比率4.7％、住院天數76.1(SD：72.3)天。第三天腦室內3-4度出血發生率之預測因子包含組別(實驗組顯著低於控制組)、出生週數、是否輸注過凝血相關血品、3天內是否有症狀的開放性動脈導管；第七天3-4度出血發生率之預測因子為出生週數和7天內是否有症狀的開放性動脈導管；死亡的預測因子為母親年齡及出生週數；加護病房住院天數中，出生週數和妊娠週數百分位為預測因子。上述的結果變項共同預測因素為出生週數。 結論：早產兒腦室內出血大多發生於出生3天內，本研究所設計之早產兒出生3天內之組合式護理措施確實對降低早產兒三天內發生3-4度以上的腦室內出血有正面的效果，但對於第七天腦室內出血、死亡及加護住院天數無顯著成效。

Background and Objectives: Intraventricular hemorrhage (IVH) is one of the serious complications in premature infants, with an incidence of approximately 25-30％ in preterm infants weighing less than 1500g, and it is associated with long-term neurological sequelae and mortality. Current methods for preventing IVH include preventing preterm birth, administering corticosteroids to the mother before delivery, treating chorioamnionitis proactively, and improving postnatal care and transport processes for preterm infants. Many foreign studies have shown that nursing interventions can reduce the risk of IVH and mortality. However, there was no global consensus and no research or data on such interventions in Taiwan. Therefore, this study aimed to investigate the effectiveness of a nursing care bundle in preventing IVH in preterm infants. Research Methods: A quasi-experimental research design was adopted, and premature infants with gestational age ≤30 weeks or birth weight ≤1500g were enrolled in the neonatal intensive care unit of a medical center in northern Taiwan. The control group was selected by retrospectively reviewing the electronic medical records in the hospital database (retrospective cohort) and identifying premature infants who met the inclusion criteria from January 1, 2017, to December 31, 2019, and linking them to their mother's files. The experimental group was enrolled prospectively and received routine care, as well as a combined nursing care approach from birth to the third day in the neonatal intensive care unit. The effectiveness assessment of the intervention included the incidence of IVH on the third and seventh days after birth, mortality rate, and length of stay in the neonatal intensive care unit. The research data were analyzed using SPSS version 26 software, and the effectiveness of the intervention was analyzed using logistic regression and multiple regression to control for the heterogeneity of independent variables between the experimental and control groups. Research Results: A total of 178 premature infants were included in this study, with 30 in the experimental group and 148 in the control group. The average gestational age of the premature infants was 28.6 ± 2.1 weeks, with an average birth weight of 1071 ± 354.9g. The proportion of male infants was slightly higher (51.7％), and the majority were singleton births (65.2％). The basic characteristics, medical issues, and treatments received by premature infants in the experimental and control groups were mostly homogeneous. However, there were significant differences in gestational age, gestational age percentile, whether coagulation-related blood products were transfused, and the presence of symptomatic patent ductus arteriosus within three days. Regarding the basic information of the mothers, only age showed a statistically significant difference (experimental group: 38.0 years; control group: 35.7 years, p=0.01). As for the results, the incidence of grade 2 or higher IVH on the third day was 6.7％ in the experimental group, with 10％ on the seventh day. The mortality rate was 0％, and the length of stay in the neonatal intensive care unit was 81.9 (SD: 73.6) days. In the control group, the incidence of grade 2 or higher IVH on the third day was 8.8％, with 8.8％ on the seventh day. The mortality rate was 4.7％, and the length of stay in the neonatal intensive care unit was 76.1 (SD: 72.3) days. The predictive factors for grade 3-4 intraventricular hemorrhage on the third day included group classification (experimental group significantly lower than control group), gestational age, whether clotting-related blood products were transfused, and the presence of symptomatic patent ductus arteriosus within three days. The predictive factors for grade 3-4 intraventricular hemorrhage on the seventh day included gestational age and the presence of symptomatic patent ductus arteriosus within seven days. The predictive factors for mortality included maternal age and gestational age. In terms of length of stay in the intensive care unit, gestational age and percentile of gestational weeks were predictive factors. The common predictive factor among the outcome variables was gestational age. Conclusion: IVH in premature infants mainly occurs within the first three days after birth. The nursing care bundle designed in this study for the first three days after birth significantly reduced the incidence of grade 3-4 intraventricular hemorrhage in premature infants. However, it did not show significant effectiveness in IVH on the seventh day, mortality, and length of stay in the neonatal intensive care unit.