危重新生儿弥散性血管内凝血前期的监测与治疗

目的探讨监测危重新生儿血浆凝血酶原片段F1＋2、凝血酶抗凝血酶复合物（TAT）及D-二聚体等凝血及纤溶因子水平对弥散性血管内凝血前期（pre-DIC）的诊断及治疗意义。方法对NICU收治的96例危重症及36例正常新生儿检测F1＋2、TAT及D-二聚体水平，对30例诊断pre-DIC的患儿予抗凝治疗，并监测治疗后F1＋2、TAT及D-二聚体水平。结果危重症组与对照组相比，F1＋2、TAT、D-二聚体水平均增高，差异有极显著性（P均〈0．01）。TAT对pre-DIC诊断的敏感性较高，F1＋2特异性强；三者在抗凝治疗后均明显下降。F1＋2与TAT、D-二聚体三者之间均呈直线正相关，F1＋2与TAT、D-二聚体的相关系数分别为r=0．70P〈0．01；r=0.42 P〈005；TAT与D-二聚体呈正相关（r=0．35 P〈0．05）；F1＋2、TAT、D-二聚体与危重评分呈直线负相关（r=-0．68、-072、-054P均〈0.01）。结论检测TAT、F1＋2、D-二聚体水平监测危重新生儿的血液高凝状态，有助于pre—DIC的诊断，并可协助判断抗凝治疗的效果。     

纤维蛋白相关标志物对重症肺炎患儿DIC前状态的诊断价值

目的探讨纤维蛋白单体(FM)、D-二聚体(D-D)、纤维蛋白(原)降解产物(FDP)3种纤维蛋白相关标志物在重症肺炎患儿弥散性血管内凝血前状态(Pre-DIC)中的诊断价值。方法 213例重症肺炎患儿根据其是否合并Pre-DIC分为Pre-DIC组和病例对照组,另选择40例健康儿童作为正常对照组。分析各组的FM、D-D、FDP、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、血小板计数(PLT)、血栓调节蛋白(TM)水平,应用受试者工作特征曲线对各指标进行比较和评价。结果三组间除FIB外其余各指标差异均有统计学意义(P均0.05),其中FM、D-D、FDP、APTT三组间两两比较差异均有统计学意义(P均0.01),Pre-DIC组最高,病例对照组次之;Pre DIC组的PT明显高于正常对照组与病例对照组(P0.05),而后两组的PT差异无统计学意义(P0.05);Pre-DIC组和病例对照组的TM和PLT均高于正常对照组(P0.01),但前两组的差异均无统计学意义(P0.05)。各指标中FM、D-D、FDP诊断重症肺炎患儿DIC前状态的曲线下面积较大,分别为0.84、0.76、0.64,三者联合诊断时曲线下面积为0.85。结论纤维蛋白相关标志物FM、D-D、FDP可作为重症肺炎患儿Pre-DIC诊断中有价值的标志物,3项联合检测可提高诊断准确性。     

Evaluation of the outcome of patients admitted to the pediatric intensive care unit in Alexandria using the pediatric risk of mortality (PRISM) score

The aim of this prospective study was to evaluate the use of pediatric risk of mortality (PRISM) score to predict the patient outcome in Alexandria Pediatric Intensive Care Unit (PICU). The study included all admissions to a tertiary care teaching hospital for 13 months. All patients were subjected to thorough history taking and clinical examination. The PRISM score was obtained within 8 h from admission (including 14 parameters with 34 variables). The primary affected system, referral site, number of organ failure on admission, length of hospital stay (LOS) and outcome of patients were recorded. The bed occupancy rate, turnover rate, average LOS, total and adjusted death rates were also recorded. Results showed that the total and adjusted mortality rates were 50 and 38 per cent respectively (n = 205/406 and 125/326, respectively). The mean PRISM score on admission was 26. Non-survivors showed a significantly higher mean score compared with survivors (36 vs. 17). Non-survivors compared with survivors, were significantly younger (12 vs. 23 months), had shorter LOS (3.8 vs. 5.3 days), three or four organ system failure on admission (77 vs. 25 per cent, and 9 vs. 0 per cent of patients) and had significantly higher percentage of sepsis syndrome and neurological diseases, as the primary affected system (20 vs. 10 per cent and 26 vs. 16 per cent). The PRISM score showed a significant positive correlation only with the number of organ failure on admission (r = 0.8104; p < 0.001). The cut-off point of survival was a PRISM score 26 with expected/observed ratio of 1.05 for non-survivors with 91.6 per cent accuracy. Multiple logistic regression analysis revealed that PRISM score, LOS, and the primary affected system were relevant predictors of patient outcome in PICU. In conclusion, the PRISM score is proved to be a good predictor of outcome for children admitted to a PICU with a cut-off point of 26. The mortality in the PICU is affected by LOS, primary system affected, and number of organ failure on admission.     

Diagnosis and stage-related treatment of disseminated intravascular coagulation in meningococcal infections.

Disseminated intravascular coagulation (DIC) is a frequent complication of meningococcal sepsis in children. Despite the availability of potent antibiotics, mortality in meningococcal disease remains high (about 10%), rising to 40% in patients presenting in severe shock and consecutive DIC. As the clinical course and the severity of manifestations of systemic meningococcal infections varies there is a need for early diagnosis of the infection and of the stage of coagulopathy in order to reduce the high mortality rate. Few and rapidly available parameters are needed to classify the wide spectrum of clinical and laboratory findings in patients with DIC. The parameters include partial thromboplastin time, prothrombin time, plasma levels of fibrinogen, antithrombin III (AT III), fibrin monomers and D-dimer concentration, fibrin degradation products and the thrombocyte count. Monitoring the course of hemostasis findings in 28 pediatric patients (age between 3 months and 8 years, mean 3.1 years) with systemic meningococcal infections we observed a change of coagulation parameters already in the first stages of the infection: A prolongation of partial thromboplastin time mean 69.1 sec (range 22-150 sec, normal 30-45 sec), a decrease of prothrombin time to 45.7% (range 13-71%, normal 70-100%) and of AT III to an average level of 70% (normal 85-125%) was found 1 to 4 (-6) hours after admission. The following deterioration of prothrombin time and partial thromboplastin time turned out to be statistically significant (p < 0.05, signed rank test). The monitoring of hemostasis parameters mentioned above made it to possible define the stage of coagulopathy and thus to start a stage related therapy. Treatment consisted of shock control by liquid substitution, compensation of metabolic acidosis, correction of clotting disorders (AT III and heparin in case of pre-DIC; AT III and fresh frozen plasma in case of advanced DIC), antibiotic treatment (beta-lactam antibiotics e.g. cefotaxime or ceftriaxone), and--when necessary--catecholamine infusions. An early assessment of the coagulation disorders in meningococcal disease can be based on few coagulation parameters. Thus an appropriate treatment can be arranged in order to prevent a fatal outcome of meningococcal sepsis and to protect against the development of a Water-house-Friderichsen-syndrome.     

Diagnosis and treatment of disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a complex clinical syndrome with activation of the procoagulant and fibrinolytic systems along with inhibitor consumption. We discuss regarding the controversies in diagnosis and management of DIC. Bleeding is a more common manifestation of DIC but most of the morbidity and mortality of DIC is due to microvascular thrombosis. Routinely performed tests for DIC such as platelet count and prothrombin time may be normal in chronic DIC. There is no single test that would diagnose DIC, however, estimation of D-dimer appears to be the most sensitive and specific test. Therapy of DIC aims at treating the primary cause. Fresh frozen plasma and platelet concentrates are recommended only in bleeding patients and have the potential risk of adding procoagulant material to the already activated procoagulant system. Role of heparin and antithrombin in patients with sepsis and DIC is discussed.     

Hypocalcaemia in a paediatric intensive care unit

Data on the incidence of hypocalcaemia in critically ill children admitted to a Paediatric Intensive Care Unit (PICU) is scarce, especially from developing countries. We have studied serum calcium in a prospective cohort of 100 children (68 boys, 32 girls), admitted consecutively to a PICU of a tertiary-care teaching hospital and correlated it with the outcome. Venous blood was obtained for serum calcium, magnesium, sodium, potassium, and arterial blood for ionized calcium and pH at admission and on every alternate day of hospital stay. Hypocalcaemia was present in 35 per cent of patients at admission and occurred in another 13 per cent during hospital stay. The incidence of hypocalcaemia (serum total calcium < 8.5 mg/dl) was 22.4, and ionized hypocalcaemia (serum ionized calcium < 3.2 mg/dl) was 32.4 episodes/100 patient days. Correlation between serum total and ionized calcium levels was not significant (r = 0.25, p = 0.089). Mortality was significantly higher in hypocalcaemic (28.3 per cent) compared with normocalcaemic (7.5 per cent) patients (p < 0.05). We conclude that hypocalcaemia is common in critically ill children admitted to a PICU and is associated with higher mortality.     

Evolution of an adenovirus outbreak in a multidisciplinary children's hospital

OBJECTIVE: To describe the course of an evolving adenovirus outbreak in a multidisciplinary children's hospital with a high-risk patient population. METHODS: Observational study in a 280-bed university hospital during June 2002. Active case finding identified children with adenovirus infection. Data are median (interquartile range) or n (%). Adenovirus infection was diagnosed in 49 children, median age 12 months (4-33). RESULTS: New cases were diagnosed over 26 days and peaked on day 17 (n = 15). Total infected inpatients peaked on days 17-21 (n = 36). Twenty-three infections (47%) were community-acquired and 26 (53%) hospital-acquired. Thirty-three children (67%) had a coexistent high-risk condition. Median hospital stay before and after diagnosis was 9 days (3-18) and 9 days (4-29), respectively. Twenty-two children (45%) were admitted to PICU. Overall hospital mortality was 22% (n = 11) and mortality attributed to adenoviral disease 12% (n = 6). Hospital mortality was similar between community- and hospital-acquired infections (22% compared to 23%) (P = 1.0). Twenty children (41%) received intravenous immunoglobulin (IVIG). Children treated with IVIG had a longer hospital stay (median 40 days vs 14 days) than those who did not receive IVIG (P = 0.01). Neither PICU mortality (29% vs 12%), nor hospital mortality (35% vs 14%), differed significantly between IVIG treated and untreated children (P = 0.76 and P = 0.16, respectively). CONCLUSION: The rapid spread of hospital-acquired adenovirus underlines the importance of effective infection control measures. Despite nosocomial infection amongst high-risk patients, mortality was similar to that of community-acquired infection. Administration of immunoglobulin was not associated with demonstrable benefit. A prospective randomized trial would be required to resolve this issue.     

Hypo- and hypermagnesemia in an Indian Pediatric Intensive Care Unit

Data on magnesium disturbances in critically ill children admitted to a Paediatric Intensive Care Unit (PICU) are scarce, especially from developing countries. We have studied occurrence and incidence of hypo- and hypermagnesaemia in children admitted to a PICU and the correlation between such disturbances and the outcome of illness. A total of 100 children (68 boys, 32 girls) aged 6 months to 12 years (mean +/- SD 4.9 + 3.5 years) admitted consecutively to a PICU were studied. At admission and on every alternate day venous blood was obtained for the estimation of serum and RBC-magnesium, serum calcium, sodium, and potassium, and arterial blood for ionized calcium and pH. This was done after ethical approval and informed consent. Hypomagnesaemia and hypermagnesaemia occurred in 60 per cent and 4 per cent of patients, respectively. The incidence of hypomagnesaemia was 30.1, and hypermagnesaemia was two episodes per 100 patient days. The incidence of low RBC-Mg was 17.3 episodes per 100 patient days. Hypomagnesaemia was most common in patients with raised intracranial pressure (63 episodes per 100 patients days). Mortality was nine-fold higher in hypomagnesaemic (30 per cent, 19 of 63) compared with normomagnaesemic (3.3 per cent, one of 30) patients. If Mg and Ca both were low, the mortality rate was 33 per cent (15 of 45 patients) in contrast to nil if both were normal (p < 0.05). We conclude that hypomagnesaemia and low RBC-Mg are a common occurrence in PICU patients and are associated with higher mortality.     

Hyperviscosity of the blood and haemostasis in the newborn infant

15 newborn infants with the hyperviscosity syndrome due to polycythaemia i.e. a central haematocrit of at least 65% and a raised whole blood viscosity, were examined for changes in their coagulation and fibrinolytic systems. 5 were thrombocytopenic but showed no other signs of activated coagulation. Neither did the only patient with positive ethanol gelation test measuring circulating fibrin/fibrinogen degradation products (FDP) appeared in only two and, with only one exception, an assay for fibrinolytic activity in plasma was negative. No defects were found in the coagulation system. Thus, in most of the patients there was no demonstrable abnormal proteolysis in the circulation. However, in such infants the normally low levels of antithrombin III (heparin cofactor activity) in combination with the impairment of the microcirculation might increase the risk of thrombotic complications. Haemodilution, preferably with plasma, is therefore advocated in the symptomatic patients.     

The influence of hemocoagulative disorders on the outcome of children with head injury

BACKGROUND: Although disseminated intravascular coagulation (DIC) and other hemocoagulative abnormalities are severe complications of head injury, their effect on clinical outcome remains unclear, particularly among children. OBJECTIVES: To evaluate the frequency of hemocoagulative abnormalities and their influence on outcome among children with head injury. STUDY DESIGN: We conducted a prospective observational study among 60 children with head injury, immediately evaluating severity of head injury (Glasgow Coma Scale, GCS); cerebral axial tomography; prothrombin time; activated partial thromboplastin time (aPTT); fibrinogen level; concentration of fibrin-fibrinogen degradation products (FDP), and platelet count. Two months after injury, we applied the Glasgow Outcome Score (GOS). Associations with GOS were evaluated using univariate and multivariate logistic models. RESULTS: Among children with severe head injury, 22.2% (6/27) developed DIC, all of whom died and had shown severe brain edema. Among those with severe head injury yet without DIC, the mortality was only 14.2%. A low GOS was significantly and independently associated with a low GCS, multiple trauma, delayed aPTT, low fibrinogen level, elevated FDP and low platelet count. Brain edema was also associated with a low GOS, though not significantly. CONCLUSIONS: In addition to GCS, type of trauma, type of brain lesion and certain coagulation abnormalities are predictors of GOS.     

银杏叶提取物对肾病综合征患儿高凝状态的影响

目的探讨银杏叶提取物对儿童原发性肾病综合征(NS)高凝状态的影响。方法将NS患儿35例,随机分为:1.治疗组(银杏叶)18例,采用泼尼松加银杏叶提取物治疗;2.对照组(双嘧达莫)17例;采用泼尼松加双嘧达莫治疗。8周为1个疗程,疗程结束后判断疗效。结果治疗8周后临床症状及血液生化指标等明显改善,两组治疗前后比较,各临床指标均有显著性差异(P均<0.01);24 h尿蛋白定量(P<0.05)和高凝状态指标明显改善。两组治疗前后凝血酶时间(PT)无显著差异(P>0.05);血浆纤维蛋白原(FIB)、血纤维蛋白原降解产物(FDP)、D-二聚体治疗前后比较均有显著性差异(P均<0.05),治疗后各指标有明显改善。结论银杏叶提取物对NS患儿高凝状态治疗有明显疗效,同时可改善临床症状,降低蛋白尿,辅助激素治疗NS安全有效。     

过敏性紫癜患儿抗凝纤溶系统标志物的动态变化

目的观察儿童过敏性紫癜(HSP)及过敏性紫癜性肾炎(HSPN)抗凝纤溶系统标志物的动态变化,了解其与HSP及HSPN疾病进展的关系。方法将2010年9月—2011年5月收治的HSP及HSPN患儿共241例,根据病史长短,分为HSP发作组(30例)、HSP半月组(27例)、HSP 1月组(23例)、HSP 2月组(20例),HSPN发作组(19例)、HSPN半月组(22例)、HSPN 1月组(28例)、HSPN 2月组(21例)、HSPN 3月组(22例)及HSPN 6月组(29例)。检测抗凝血酶Ⅲ活性(ATⅢ-%)、血浆D-二聚体(D-dimer)、纤维蛋白原降解产物(FDP)、血小板(PLT)、C反应蛋白(CRP)、24 h尿蛋白定量(24U-TP)及尿红细胞定量水平,并与对照组35例健康体检儿童比较。结果 HSP患儿的ATⅢ-%在2个月内渐降至正常水平,多组之间比较差异有统计学意义(P<0.001);HSPN患儿的ATⅢ-%在6个月内渐降至正常水平,多组之间比较差异有统计学意义(P<0.001);HSP及HSPN患儿的PLT在2个月内渐降至正常水平,D-dimer、FDP和CRP在半个月内渐降至正常水平,多组之间比较差异有统计学意义(P均<0.001);HSPN患儿发作期的ATⅢ-%与PLT水平高于HSP患儿(P均<0.05);HSP患儿的CRP与D-dimer呈正相关(r=0.451,P<0.001);HSPN患儿的CRP与D-dimer、FDP呈正相关(r=0.525、0.367,P均<0.001);HSPN患儿的ATⅢ-%与PLT、24U-TP之间呈正相关(r=0.407、0.497,P均<0.001)。结论 HSP及HSPN患儿发作期抗凝纤溶系统处于高活动状态,HSPN患儿更明显,随着临床症状的消失,其高活动状态逐渐恢复;ATⅢ的高活动状态可能与HSPN的进展有一定的关系。     

Prediction of mortality by application of PRISM score in intensive care unit.

OBJECTIVE: Prediction of mortality by application of Pediatric Risk of Mortality (PRISM) score in Pediatric Intensive Care Unit (PICU) patients under Indian circumstances. DESIGN: Prospective study. SETTING: PICU of a tertiary care multi-specialty hospital. METHODS: 100 sick pediatric patients admitted consecutively in PICU were taken for this study. PRISM score was calculated. Hospital outcome was recorded as (died/survived). The predicted death was calculated by the formula: RESULTS: Of 100 patients, 18 died and 82 survived. By PRISM score 49 children had the score of 1-9. The expected death in this group was 10.3% (n = 5.03) and the observed death was 8.2% (n = 4). Among 45 children with the score of 10-19, the expected mortality was 21.2% (n = 9.6) and observed was 24.4% (n = 11). There were 3 patients with the score of 20-29, the expected mortality in this group was 39.3% (n = 1.18) and observed mortality 33.3% (n = 1). There were 3 patients with score > or = 30, observed death 66.3% (n = 2) and expected mortality was 74.7% (n = 2.24). There was no significant difference between expected and observed mortality in any group. (p > 0.5). ROC analysis showed area under the curve of 72%. CONCLUSION: PRISM score has good predictive value in assessing the probability of mortality in relation to children admitted to a PICU under Indian circumstances.     

Intravenous polyclonal immunoglobulin administration to sepsis syndrome patients: a prospective study in a pediatric intensive care unit

Life-threatening infections account for about 25 per cent of children requiring admission to pediatric intensive care units (PICU). The results of the use of polyclonal intravenous immunoglobulins as an adjuvant in pediatric sepsis syndrome therapy are conflicting. A prospective study of 100 sepsis syndrome PICU patients aged 1-24 months and divided into two matching groups (septic cases and control, 50 patients each) was performed. All patients were treated according to the routine protocol PICU therapy. Only the cases group received, in addition, polyclonal IVIG (Pentaglobin, Biotest) in a dose of 400 mg/kg for 3 days. All cases were evaluated for PRISM III score 8 h after admission; routine blood, urine, stool and cerebrospinal fluid (whenever appropriate) culture. Daily laboratory examination (blood gases, electrolytes, liver and renal functions, complete blood picture and C-reactive protein) were performed for the first 5 days. Blood samples were obtained for evaluation of tumor necrosis factor-alpha (TNF-alpha) daily for the first 5 days. Referral site (ward or casuality), length of PICU stay (LOS) and outcome (discharged or deceased), the number and percentage of cases who progressed to complications were recorded. Results showed that group I had a significantly higher percentage of discharged cases (72 per cent vs. 44 per cent), significantly shorter LOS (6.1 days vs. 9.1 days), and a significantly lower percentage of progress to complications (8 per cent vs. 32 per cent) especially disseminated intravascular coagulation (4 per cent vs. 24 per cent). TNF-alpha was significantly reduced among septic cases on discharge (2.24 vs. 3.6 mg/dl, p<0.001). A multiple logistic regression model revealed that treatment with IVIG, LOS, severity of sepsis and lymphocyte percentage (L per cent) on admission were significant predictors for survival. In summary the study revealed that the use of polyclonal IVIG among PICU sepsis syndrome showed a significant reduction in mortality, LOS and less progress to complications. A multicenter study is recommended to confirm these results.     

Hemostatic changes in neonates with anoxia and sepsis

Hemostatic profile (prothrombin time (PT), thrombin time (TT), kaolin cephalin clotting time (KCCT), plasma fibrinogen, serum fibrin/fibrinogen degradation products (FDP) and platelet counts) was examined in 153 neonates with birth anoxia and 86 with sepsis. Remarkable hemostatic alterations occurred in neonates with severe anoxia and sepsis, while those with moderate anoxia exhibited minimal or no change. Vitamin K administration to anoxic babies showed no improvement in the hemostatic profile after 48-72 hours. The hemostatic alterations were presumably due to incipient disseminated intravascular coagulation (DIC). In spite of the marked coagulation changes, only 3 neonates with sepsis and none of the anoxic newborns presented with clinical bleeding indicating a well balanced hemostatic mechanism.     

不同胎龄早产儿凝血功能及出血性疾病的临床研究

目的 分析早产儿凝血功能与胎龄间的相关性,并探讨凝血功能检测对出血性疾病的可能预测价值。方法 收集2016年9月至2017年8月住院的早产儿的相关临床资料以及生后2 h内凝血功能检测结果。依据胎龄分为晚期早产儿组（n=322）、早期早产儿组（n=241）和超/极早产儿组（n=128）,比较不同胎龄各组早产儿的凝血功能;并比较生后3 d内有无并发出血性疾病早产儿的凝血功能检测指标。结果 不同胎龄的3组间凝血酶时间（TT）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、纤维蛋白原降解产物（FDP）、D-二聚体（DD）的比较差异有统计学意义（P < 0.05）,其中APTT、PT、FDP、DD与胎龄呈负相关,而TT与胎龄呈正相关（P < 0.05）。与未患出血性疾病的早产儿相比,罹患出血性疾病早产儿的APTT延长（P < 0.05）,DD值升高（P < 0.05）。结论 早产儿随着胎龄的增长,生后凝血功能逐渐成熟。APTT及DD检测结果异常,预示早产儿可能会具有更高的风险罹患出血性疾病。     

One year study of bacterial and fungal nosocomial infections among patients in pediatric intensive care unit (PICU) in Alexandria

A 1-year prospective and observational study included all admissions (n=216) until 48 h after discharge to Alexandria PICU between first of May 2003 and end of April 2004. Cultures for bacteria and fungi and antibiotic sensitivity tests (19 antibiotic using Bauer-Kirby disc diffusion method) were obtained (blood, stool, urine and cerebrospinal fluid, if needed) and repeated on suspicion of NIs. All cannulae, endotracheal tube (ET) aspirates and tips, nasogastric tubes and different catheters were cultured. All PICU health care workers (HCWs) were subjected to throat and under-finger nails cultures as well as inanimate objects, both on bimonthly basis. The referral place (ward or emergency), PRISM III score, length of stay (LOS) and fate were recorded. Amongst those patients whose age ranged from 1 to 23 months, 23 per cent had NIs with infection rates of 40/1000 days. Significantly high rates of mortality, LOS and PRISM III score were encountered among patients with NIs (52 per cent vs 30 per cent; 9.4+/-4.8 vs 5.4+/-2.2 days; 14.4+/-7 vs 11.8+/-6 respectively). The descending order of frequency of NIs was blood stream infection (BSI) (47 per cent), urinary tract infection (UTI) (28 per cent), ventilator-associated pneumonia (VAP) (16 per cent) and meningitis (9 per cent). Gr-ve bacilli accounted for 76.7 per cent; Gr+ve cocci 13.3 per cent (with satisfactory sensitivity to cefepime, imipenem and meropenem) and Candida albicans 10 per cent of all NIs. The rate of NIs/1000 device days were: 18.7 per cent for BSI, 10.9 per cent for VAP and 25.5 per cent for UTI. Vulnerable age groups were >6 m for VAP and <6 m for meningitis. Multiple logistic regression analysis identified LOS, PRISM III score and referral from wards a predictors of NI acquisition (odd ratio and 95 per cent confidence interval: 1.537, 1.423-1.659; 1.073, 1.041-1.105 and 0.269, 0.178-0.406 respectively). Bimonthly cultures for HCWs isolated coagulase-ve Staphylococci, while inanimate objects isolated diphtheroids and Candida albicans. CONCLUSION: NIs rate was high (23 per cent) mainly due to severity of condition on admission as shown by high PRISM III score value, the high PRISM III score, LOS and referral from wards were predictors of acquisition of NIs and there is a high incidence of Candida albicans infection (10 per cent of NIs).     

Distinction between fibrinogen and fibrin degradation products produced during disseminated intravascular coagulation in childhood

Fibrin-fibrinogen degradation products in serum from five children with disseminated intravascular coagulation (DIC) were characterized using a method of immunoabsorption followed by SDS-polyacrylamide gel electrophoresis. All of the samples contained not only fragment D-dimer which was produced on plasmin lysis of cross-linked fibrin, but also fibrinogen degradation products (fragments X, Y and D). These results suggest that both fibrinogenolysis and fibrinolysis take place simultaneously in DIC.     

Paediatric intensive care in Kuala Lumpur, Malaysia: a developing subspecialty

Paediatric intensive care in Malaysia is a developing subspecialty with an increasing number of specialists with a paediatric background being involved in the care of critically ill children. A part prospective and part retrospective review of 118 consecutive non-neonatal ventilated patients in University Hospital, Kuala Lumpur was carried out from 1 June 1995 to 31 December 1996 to study the clinical epidemiology and outcome in our paediatric intensive case unit (PICU). The mean age of the patients was 33.9 +/- 6.0 months (median 16 months). The main mode of admission was emergency (96.6 per cent) with an overall mortality rate of 42 per cent (50/118). The mean paediatric risk of mortality (PRISM) score was 20 +/- 0.98 SEM, with 53 per cent of patients having a score of over 30 per cent. Multiorgan dysfunction (MODS) was identified in 71 per cent of patients. Admission efficiency (mortality risk > 1 per cent) was 97 per cent. Standardized mortality rate using PRISM was an acceptable 1.06. The main diagnostic categories were respiratory (32 per cent), neurology (22 per cent), haematology-oncology (18 per cent); the aetiology of dysfunction was mainly infective. Non-survivors were older (29.5 vs. 13.8 months, p < 0.0001), had more severe illness (mean PRISM score 30 vs. 14, p < 0.0001), were more likely to develop MODS (96 vs. 53 per cent, p < 0.0001) and required more intervention and monitoring. Paediatric intensive care in Malaysia differs widely from that in developed countries in patient characteristics, severity of illness, and care modalities provided.     

Metabolism of fibrinogen in children with acute lymphoblastic leukaemia

The metabolism and in vivo kinetics of fibrinogen were studied using homologous ¹²⁵I-labelled fibrinogen in 21 children with acute lymphoblastic leukaemia (ALL). Ten patients were undergoing induction therapy, 11 children were in complete remission on maintenance therapy.Results in the patients undergoing induction therapy were: plasma fibrinogen levels were normal in all except one patient, the plasma fibrinogen pool was elevated in six cases, seven patients had a shortened fibrinogen half-life and increased fractional catabolic rate for fibrinogen. The absolute catabolic rate for fibrinogen was elevated in six cases. This shortened fibrinogen half-life together with the correcting effect of heparinisation on the fibrinogen turnover indicated that fibrinogen was consumed by chronic disseminated intravascular coagulation. Inhibition of the fibrinolytic system with epsilon-aminocaproic acid in five patients had no influence on the fibrinogen half-life in three of them but resulted in its prolongation in two patients.All except two children in complete remission had normal fibrinogen levles. Six patients had elevated plasma fibrinogen pools and in all of the cases survival and fractional catabolic rate of fibrinogen were normal. The absolute catabolic rate for fibrinogen was normal in eight, elevated in three of the patients. This observation indicates that fibrinogen synthesis remains accelerated in some cases of ALL in complete remission, but the cause of this is not known.Abbreviations ALL acute lymphoblastic leukaemia - DIC disseminated intravascular coagulation - PTT partial thromboplastin time - PT prothrombin time - TT thrombin time - EG ethanol gelation test - ELT euglobulin clot lysis time - FDP fibrinogen/fibrin degradation products - FCR fractional catabolic rate constant - ACR absolute catabolic rate - IFP intravascular plasma fibrinogen pool - PV plasma volume