儿科重症监护室早产儿肺部感染危险因素分析与防治对策

目的 分析儿科重症监护室(PICU)早产儿肺部感染的危险因素,并提出针对性的防治对策.方法 回顾性分析肺部感染早产患儿158例和未发生肺部感染早产儿139例,先对纳入的所有危险因素进行单因素分析筛选出有统计学意义的变量,再使用逐步Logistic 回归分析确定独立危险因素,并实施针对性护理措施.结果 单因素分析显示,胎龄、出生时体质量、1 min Agar评分及是否患基础疾病、昏迷、雾化吸入、插管方式、上机前48 h 使用抗生素、无创正压通气、痰培养细菌阳性、PICU住院时间、机械通气时间、无创正压通气时间、静脉营养及吸氧时间等15项因素差异有统计学意义(P<0.05);多元回归分析只有出生体质量、机械通气时间和昏迷是PICU内肺部感染的主要危险因素,OR值分别为3.851、2.048和6.357.结论 通过对早产儿肺部感染患儿危险因素研究分析,制定出科学的护理对策,可有效降低PICU内早产儿罹患肺部感染的风险.     

A comparison of the phenomenology of pediatric, adult, and geriatric delirium

BACKGROUND: The phenomenology of delirium in childhood is understudied. OBJECTIVE: The objective of the study is to compare the phenomenology of delirium in children, adults and geriatric patients. POPULATION AND METHODS: Forty-six children [mean age 8.3, S.D. 5.6, range 0-17 years (inclusive)], admitted to the pediatric intensive care unit of Maastricht University Hospital, with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delirium, underwent assessment with the Delirium Rating Scale (DRS). The scores are compared with those of 49 adult (mean age 55.4, S.D. 7.9, range 18-65 years) and 70 geriatric patients (mean age 76.2, S.D. 6.1, range 66-91 years) with DSM-IV delirium, occurring in a palliative care unit. Score profiles across groups, as well as differences in individual item scores across groups are analysed with multiple analysis of variance, applying a Bonferroni correction. RESULTS: Although the range of symptoms occurring in all three groups was similar, DRS score profiles differed significantly across the three groups (Wilks lambda=0.019, F=804.206, P<.001). On item level, childhood delirium is characterized by a more acute onset, more severe perceptual disturbances, more frequent visual hallucinations, more severe delusions, more severe lability of mood, greater agitation, less severe cognitive deficits, less severe sleep-wake cycle disturbance, and less variability of symptoms over time. Adult and geriatric delirium do not differ in their presentations, except for the presence of more severe cognitive symptoms in geriatric delirium (P=.001). CONCLUSION: Childhood delirium has a different course and symptom profile than adult and geriatric delirium. Adult and geriatric delirium differ only in the severity of cognitive symptoms.     

Relationship of serum C-reactive protein and blood glucose levels with injury severity and patient morbidity in a pediatric trauma population

Purpose

Serum markers of inflammation and of glucose production are known to reflect the immediate metabolic response to injury. We hypothesized that monitoring of the early C-reactive protein (CRP) and blood glucose (BG) concentrations would correlate with clinical morbidity and outcome measures in pediatric trauma patients.

Methods

A five-year retrospective chart review of pediatric trauma patients admitted to our Level I pediatric trauma center was conducted to establish the relationships between early (first 3 hospital days) serum CRP and BG concentrations, Injury Severity Score (ISS), and hospital length of stay (HLOS). Statistical significance (P < 0.05) was determined using Student’s t-test.

Results

Forty-two trauma patients (8.0 ± 5.2 years) were evaluated. The early inflammatory response (CRP ≥ 10 vs <10 mg/dl) was significantly correlated to the glycemic response (BG;121 ± 24 vs 97.3 ± 14.2 mg/dl, P < 0.05). Severely injured patients (ISS ≥ 25 vs <25) were significantly more hyperglycemic (BG;156 ± 56.9 vs 125 ± 31.6 mg/dL, P = 0.003). Both increased inflammatory response (CRP;8.1 ± 6.4 vs 2.5 ± 3.5 mg/dL) and increased glycemic response (BG;111 ± 15.9 vs 97.4 ± 11.7 mg/dL) were independently and significantly associated with prolonged hospitalization (HLOS > 7 vs ≤7 days, P < 0.05).

Conclusion

This study establishes a significant relationship between the early inflammatory and glycemic injury response and the association of that response with pediatric trauma patient morbidity and outcome measures.     

Nosocomial bloodstream infection in a pediatric intensive care unit

Objective  To study the incidence of nosocomial blood stream infections (BSI) in a pediatric intensive care unit (PICU) of a tertiary care teaching hospital, identify the organisms responsible and the pattern of antibiotic resistance over one decade. Methods  Data was retrieved from the records of PICU and Medical Microbiology laboratory of patients with a positive blood culture after 48 hours of admission to PICU over three time periods viz. 1994–1996, 1999–2001 and 2002–2003. Antibiotic sensitivity pattern was also analyzed. Results  861 episodes (1994–1996: 282, 1999–2001: 362 and 2002–2003: 217) of nosocomial bloodstream infection were documented in 841 patients, corresponding to 3.63, 5.94 and 4.99 episodes per 100 patient-days, respectively. Gram negative organisms were the predominant isolates; common being Klebsiella pneumoniae (20.1%), Enterobacter species (16.6%) and Acinetobacter species (8.6%). Staphylococcus aureus (16.4%) and yeast species (15.9%) were the major Gram positive isolates. Isolation of Staphylococcus aureus, Klebsiella and Acinetobacter species showed a rising trend while yeast (36.9%, 6.6% and 4.1%) showed a decline over the three time periods studied. An increasing trend of resistance to third generation cephalosporins, aminoglycosides, ciprofloxacin and newer antibiotics including combination of beta-lactam with beta-lactamase inhibitor was noted. Conclusion  The predominant organisms responsible for nosocomial infection in the PICU were Klebsiella pneumoniae, Staphylococcus aureus and Enterobacter species. At present, carbapenams plus vancomycin appear to be the best choice for empiric antibiotic therapy in the PICU in Chandigarh.     

Health-related quality of life after a drowning incident as a child

Aim of the study

To describe health-related quality of life (HRQoL), quality-adjusted life years (QALYs) gained and school performance in subjects having received either bystander or emergency medical service personnel initiated cardiopulmonary resuscitation (CPR) after a drowning incident in childhood.

Materials and methods

64 children admitted to pediatric intensive care (PICU) after successful CPR between 1985 and 2007. Eleven died in the PICU, 9 other within 6 months. In 2009 all long-term survivors, except for two, lived at home. Of the 40 patients eligible for the study, 29 (73%) responded to a questionnaire. HRQoL was assessed with the generic 15D, or its versions for adolescents (16D) or children (17D), and compared to that of general population. These HRQoL scores, age-specific survival probabilities, and HRQoL scores of the general population were used in a Markov model to estimate the number of QALYs gained.

Results

Median age of the respondents was 17.3 (range: 3.0–28.4) years and 62% were male. At the time of drowning their median age had been 3.0 (range: 1.2–15.7) years. The drowning incident was associated with a significant loss in HRQoL in the oldest age group (total HRQoL total score 0.881 compared to 0.971 in the general population, P < 0.01) but not in children (HRQoL score 0.944 vs. 0.938). When submersion time exceeded 10 min mean HRQoL score was significantly lower than in patients with a shorter submersion (0.844 vs. 0.938, P = 0.032). The mean undiscounted and discounted (at 3%) number of QALYs gained by treatment were 40.8 and 17.0, respectively.

Conclusions

A good HRQoL will be achieved in the majority of patients surviving long-term after a drowning incident in childhood, although HRQoL is affected by the submersion time.     

儿科重症监护病房呼吸道医院感染的分析及预防

目的 探讨儿科重症监护病房（PICU）呼吸道医院感染的原因和预防措施。方法 对2005年1—12月PICU气管插管痰培养和胸片结果阳性患儿的临床资料进行回顾性研究。结果 下呼吸道痰标本8例阳性，11张胸片结果提示肺内炎症。结论 了解PICU机械通气患儿下呼吸道感染的原因，加强培训、严格执行预防医院感染的措施、加强监测等是预防PICU医院感染的主要措施。