In order to guide medical personnel to standardize the rescue and related treatment of preterm and low weight newborns, reduce the occurrence of retinopathy of prematurity and improve the quality of survival of preterm and low weight newborns, the Ministry of Health commissioned the Chinese Medical Association to organize experts in pediatrics, perinatal medicine, neonatal intensive care, ophthalmology and other specialties to conduct special research on the treatment of oxygen and prevention of retinopathy of prematurity, summarize The guidelines for the treatment of oxygen and prevention of retinopathy in preterm infants were formulated for medical personnel to follow in the course of practice.
With the development of medical science and medical technology, the survival rate of premature and low weight newborns has been increasing, and many premature and low weight newborns that were difficult to survive under the original medical conditions have survived. However, some problems such as retinopathy of prematurity and bronchopulmonary dysplasia, which are caused by the underdevelopment of organs of preterm infants and the intervention of medical treatment measures, are also gradually revealed. According to the World Health Organization, retinopathy of prematurity has become the leading cause of childhood blindness in high-income countries. This problem has attracted great attention from medical academia both at home and abroad.
The Ministry of Health requires that during the implementation of the Guidelines, health administrative departments and medical institutions should organize targeted training for medical personnel on the use of oxygen for rescue treatment of premature infants and the prevention, diagnosis and treatment of retinopathy, with emphasis on strengthening training for medical personnel specializing in obstetrics, pediatrics and ophthalmology, so that they can correctly apply rescue measures for premature infants in accordance with the Guidelines, identify premature infants at an early stage, and reduce the risk of retinopathy. Retinopathy and reduce the rate of blindness. A referral system should be established between medical institutions. Medical institutions, especially primary care providers, should raise awareness of retinopathy of prematurity, strengthen follow-up of preterm infants, and promptly direct preterm infants to medical institutions that are qualified for examination, diagnosis or treatment. Health administrative departments should strengthen the guidance and supervision of medical institutions in the implementation of the Guidelines, focusing on strengthening the supervision and inspection of obstetrics, pediatrics and ophthalmology medical staff to master the Guidelines and the implementation of the referral system in medical institutions.
April 27, 2004
Annex
Guidelines for the Treatment of Premature Infants with Oxygen and Retinopathy
In the past 10 years, with the rapid development of perinatal medicine and neonatology in China and the establishment of neonatal intensive care units (NICUs), the survival rate of preterm and low birth weight infants has increased significantly. The incidence of retinopathy of prematurity (ROP) and broncho-pulmonary dysplasia (BPD), which were previously seen in developed countries, is on the rise in China. Retinopathy of prematurity (hereinafter referred to as ROP) is an ocular disease that occurs in preterm infants and can lead to blindness in severe cases. The causes are multifaceted and closely related to prematurity and immature retinal vascular development. The smaller the gestational age and weight, the higher the incidence. With the improvement of the level of neonatal resuscitation in China, the incidence of ROP has increased accordingly as the preterm infants who were not viable have survived.
In developed countries, ROP is the major ocular disease causing blindness in pediatric patients, appearing as early as 32 weeks of corrected gestational age (gestational weeks + postnatal weeks), with threshold lesions appearing at approximately 37 weeks of corrected gestational age, and early screening and treatment can stop the progression of the lesions. In order to solve this problem that seriously affects the quality of survival of preterm infants, and to do a good job in the prevention and treatment of ROP and minimize the occurrence of ROP, the Chinese Medical Association has formulated the Guidelines for the Treatment of Preterm Infants with Oxygen and Retinopathy for clinical application.
Oxygen for preterm infants
I. Indications for oxygen administration
The clinical manifestation of respiratory distress with arterial partial pressure of oxygen (PaO2) <50 mmHg or transcutaneous oxygen saturation (TcSO2) <85%< font=""> at the time of air inhalation. The goal of treatment is to maintain PaO2 50-80 mmHg, or TcSO2 90%-95%.
2. Oxygen therapy and respiratory support modalities
1. Oxygenation by hood or modified nasal cannula: for children with mild respiratory distress. The oxygen concentration depends on the need of the disease, about 40% oxygen can be tried at the beginning, and adjusted according to PaO2 or TcSO2 after 10-20 minutes. If high oxygen concentration (>40%) is needed for a long time to maintain stable PaO2, assisted breathing should be considered.
2. Nasal plug continuous positive airway pressure oxygenation (nCPAP): early application can reduce the need for mechanical ventilation. Pressure 2-6cmH2O, flow rate 3-5L/min. CPAP device equipped with air and oxygen mixer should be applied in order to adjust oxygen concentration and avoid pure oxygen inhalation.
3. Mechanical ventilation: When clinically exhibiting severe respiratory distress, with inhalation oxygen concentration (FiO2) >0,5, PaO2 <50 mmhg< font="">, PCO2 >60 mmHg or other indications for mechanical ventilation, tracheal intubation mechanical ventilation is required.
Caution
1. Strictly grasp the indications for oxygen therapy. Oxygen is not necessary for those with no clinical cyanosis, no respiratory distress, and normal PaO2 or TcSO2. For premature infants with apnea, the main treatment should be directed at the cause, and oxygen should be intermittently administered when necessary.
2. During oxygen therapy, FiO2, PaO2 or TcSO2 should be closely monitored. At different levels of respiratory support, PaO2 50-80 mmHg and TcSO2 90-95% should be maintained at the lowest oxygen concentration. During mechanical ventilation, when the child’s condition improves and blood gas improves, FiO2 should be lowered in time. adjustment of oxygen concentration should be done gradually to avoid excessive fluctuations.
3. If the child’s demand for oxygen concentration is high and there is no improvement even after a long time of oxygen intake, the cause should be actively investigated, and the treatment plan should be readjusted and treated accordingly.
4. When using oxygen to preterm infants, especially very low weight infants, parents must be informed of the immaturity of the blood vessels of preterm infants, the necessity of using oxygen to preterm infants and the possible hazards.
5. All preterm infants who have undergone oxygen therapy and meet the criteria for ophthalmic screening should be screened for ophthalmic ROP at 4-6 weeks after birth or at 32-34 weeks of corrected gestational age for early detection and early treatment.
6. Oxygen therapy for preterm infants must be performed with appropriate monitoring conditions, such as oxygen concentration meter, blood gas analyzer or transcutaneous oxygen saturation meter, etc. If oxygen therapy monitoring conditions are not available, the infant should be transferred to a hospital with the conditions for treatment.
Diagnostic and current screening criteria for retinopathy of prematurity
I. Clinical signs
1. The site of ROP is divided into 3 zones: zone 1 is the center of the optic disc, and the distance from the center of the optic disc to the central macular concavity is drawn as a circle with a radius of 2 times; zone 2 is the center of the optic disc, and the center of the optic disc to the nasal serrated edge is drawn as a circle with a radius; the remaining part outside zone 2 is zone 3. The more backward the early lesion is, the greater the risk of progression.
2. The severity of the lesion is divided into 5 stages: stage 1 occurs at approximately 34 weeks of corrected fetal age, and a demarcation line appears between the vascular and nonvascular areas in the temporal periphery of the retina in the fundus; stage 2 occurs at an average of 35 weeks (32-40 weeks), and the demarcation line in the fundus is elevated with ridge-like changes; stage 3 occurs at an average of 36 weeks (32-43 weeks), and retinal vascular dilatation and proliferation occurs on the ridge of the demarcation line in the fundus, accompanied by In stage 4, tractional retinal detachment occurs due to fibrovascular proliferation, starting at the periphery and gradually progressing to the posterior pole; this stage is divided into A and B according to the presence or absence of macular detachment, A without macular detachment and B with macular detachment. 5, total retinal detachment occurs (approximately 10 weeks after birth). “Plus” disease refers to dilated and tortuous retinal blood vessels in the posterior pole, and a “+” is written next to the stage of the lesion when “Plus” disease exists, e.g., stage 3 +. “Pre-threshold ROP” indicates that the lesion will progress rapidly, requiring a shorter review interval and close observation of the condition, including: any lesion in zone 1, stage 2 + in zone 2, stage 3, stage 3 +. Threshold lesions include: stage 3 + of zone 1 and 2 adjacent lesions up to 5 clock points consecutively, or up to 8 clock points cumulatively, which are lesions that must be treated.
3. Advanced lesions with shallow or absent anterior chamber can be secondary to glaucoma and corneal degeneration.
II. Diagnostic points
Medical history: premature and low birth weight infants.
Clinical manifestations: The appearance of a demarcation line between the avascular and avascular areas of the retina in the early stage of the lesion is a clinical characteristic sign of ROP. Proliferative lesions at the demarcation, abnormal retinal vascular alignment, and varying degrees of retinal detachment by traction, and late changes should be considered for the diagnosis of ROP.
Screening criteria
1. screening for fundus lesions should be initiated in preterm and low birth weight infants with birth weight <2000g< font=""> and followed until peripheral retinal vascularization.
2. screening may be appropriately expanded for preterm infants with severe disease
3. The first examination should be started at 4-6 weeks after birth or 32 weeks of corrected gestational age.
The examination should be performed by an ophthalmologist with sufficient experience and relevant knowledge.
IV. Treatment principles
1. regular follow-up of stage 1 and 2 lesions in zone 3
2. close observation of the condition for pre-threshold lesions (any lesion in zone 1, stage 2 + in zone 2, stage 3, stage 3 +)
3. indirect fundoscopic photocoagulation or condensation for threshold lesions (stage 3+ lesions in zones 1 and 2 for up to 5 consecutive clock points or up to 8 clock points cumulatively)
4. surgical treatment can be performed for stage 4 and 5 lesions.