减少严重营养不良儿童不必要的输血和静脉输液不足以降低死亡率。

Reduction of unnecessary transfusion and intravenous fluids in severely malnourished children is not enough to reduce mortality.

作者信息

Bachou Hanifa, Tumwine James K, Mwadime Robert K N, Ahmed Tahmeed, Tylleskar Thorkild

机构信息

Department of Paediatrics & Child Health, School of Medicine, Makerere University, Kampala, Uganda.

出版信息

Ann Trop Paediatr. 2008 Mar;28(1):23-33. doi: 10.1179/146532808X270644.

DOI:10.1179/146532808X270644

PMID:18318946

Abstract

AIM

To test whether standardising the use of blood transfusions and intravenous (IV) infusions could reduce fatality in severely malnourished children admitted to Mulago Hospital, Kampala.

METHODS

Improved adherence to the WHO protocol for blood transfusion and IV fluids was effected in patients with severe malnutrition by continuous medical education. A 'before and after' design was used to study 450 severely malnourished children (weight-for-height < -3 Z-score or presence of oedema) under 60 months of age. A total of 220 pre- and 230 post-'improved practice' patients were enrolled consecutively during the periods September to November 2003 and September to December 2004, respectively. Patients were followed up until discharge or death. The Kaplan-Meier survival curve and the Cox regression hazard model were used for univariate and multivariate analyses, respectively.

RESULTS

Overall case fatality was 23.6% (52/220) in the pre-period and 24.8% (57/230) in the post-period (p=0.78). Most of the deaths occurred in the 1st week of admission (73%, 38/52 in the pre-period and 61%, 35/57 in the post-period) and were of children who had received blood transfusion or IV infusion or both in the pre-period. Mortality in children transfused and/or infused was significantly reduced in the post-period (82%, 31/38 in the pre-period vs 23%, 8/35 in the post-period, p=0.008). In the post-period, there was a significant reduction in the number of inappropriate blood transfusions (18%, 34/194 vs 3.5%, 8/230, p=0.01) and IV fluid infusions (27%, 52/194 vs 9%, 20/230, p<0.001). Survival improved in children who received blood transfusions in the post-period [hazards ratio (HR) 0.22, 95% CI 0.30-1.67 vs HR 4.80, 95% CI 1.71-13.51], as did that of children who received IV infusions (HR 2.10, 95% CI 0.84-5.23 vs HR 3.91, 95% CI 1.10-14.04).

CONCLUSION

Management according to the WHO protocol for severe malnutrition can reduce the need for blood and IV infusions. However, further studies are required to verify whether full implementation of the WHO protocol reduces the high case fatality in sub-Saharan hospitals.

摘要

目的

测试规范输血和静脉输液的使用是否能降低坎帕拉穆拉戈医院收治的重度营养不良儿童的死亡率。

方法

通过持续医学教育，使重度营养不良患者更好地遵循世界卫生组织（WHO）的输血和静脉输液方案。采用“前后”设计，研究450名60个月以下的重度营养不良儿童（身高别体重＜-3 Z评分或有水肿）。分别于2003年9月至11月和2004年9月至12月连续纳入220名“改进措施”实施前和230名实施后的患者。对患者进行随访直至出院或死亡。分别采用Kaplan-Meier生存曲线和Cox回归风险模型进行单因素和多因素分析。

结果

前期总体病死率为23.6%（52/220），后期为24.8%（57/230）（p = 0.78）。大多数死亡发生在入院的第1周（前期73%，38/52；后期61%，35/57），且是前期接受过输血或静脉输液或两者皆有的儿童。后期接受输血和/或输液儿童的死亡率显著降低（前期82%，31/38；后期23%，8/35，p = 0.008）。后期，不适当输血的数量显著减少（18%，34/194；3.5%，8/230，p = 0.01），静脉输液数量也显著减少（27%，52/194；9%，20/230，p＜0.001）。后期接受输血儿童的生存率有所提高[风险比（HR）0.22，95%置信区间0.30 - 1.67；前期HR 4.80，95%置信区间1.71 - 13.51]，接受静脉输液儿童的生存率也有所提高（HR 2.10，95%置信区间0.84 - 5.23；前期HR 3.91，95%置信区间1.10 - 14.04）。