Prevalence and factors associated with surfactant use in Brazilian Neonatal Intensive Care Units: A multilevel analysis

Abstract The treatment with exogenous surfactant reduces mortality and the risk of complications in preterm newborns with Respiratory Distress Syndrome. Higher usage levels have been associated with individual and institutional factors. The study aimed to identify these factors associated with use of this technology in 16 public Brazilian Neonatal Units using logistic multilevel analysis. In a sample of 630 newborns the use at some time was 82.6%. Only 24.7% made use of this technology up to two hours after birth. An intraclass correlation of 0.30 showed that 30% of the variance in the use of exogenous surfactant could be assigned to the contextual level. In the final model, a greater severity score (SNAPPE-II) was associated with increased surfactant use (OR = 2.64), whereas being small for gestational age (SGA) (OR = 0.59) was associated with lower use of this technology. At the contextual level the number of beds in the unit >15 (OR = 5.86), units with higher complexity (OR = 1.73) or units with implemented Kangaroo Mother Care (OR = 2.91), especially units in Rio de Janeiro state (OR = 16.17) were associated with greater surfactant use. Although individual clinical features explained most of the variation in the use of this technology, factors linked to the institution were also of utmost importance.

摘要
外源性肺表面活性物质治疗可降低合并呼吸窘迫综合征（Respiratory Distress Syndrome，RDS）的早产新生儿的死亡率与并发症发生风险。该技术的使用水平与个体及机构层面的多重因素相关。本研究采用多水平logistic回归分析方法，旨在明确巴西16家公立新生儿科单位中，与外源性肺表面活性物质使用相关的影响因素。
本研究纳入630名新生儿作为研究对象，其中82.6%的新生儿曾在病程中接受该治疗，仅24.7%的新生儿在出生后2小时内启动了该治疗方案。组内相关系数为0.30，提示外源性肺表面活性物质使用情况的总变异中有30%可归因于机构层面的差异。
最终模型分析结果显示：更高的新生儿急性生理学评分联合围产期扩展版Ⅱ（Score for Neonatal Acute Physiology with Extended Paediatric Perinatal II，SNAPPE-II）严重程度评分与肺表面活性物质使用概率升高显著相关（优势比OR=2.64）；而小于胎龄儿（small for gestational age，SGA）则与该技术的使用概率降低相关（OR=0.59）。在机构层面，床位数量＞15的新生儿科单位（OR=5.86）、复杂度更高的单位（OR=1.73）或开展袋鼠式护理（Kangaroo Mother Care，KMC）的单位（OR=2.91），尤其是位于里约热内卢州的单位（OR=16.17），均与肺表面活性物质的使用概率升高显著相关。
尽管个体临床特征可解释该技术使用情况的大部分变异，但机构层面的相关因素同样至关重要。