小儿危重病例评分与儿童死亡风险评分对重症手足口病病情评估和病情进展预测的作用

【目的】比较分析小儿危重病例评分（Pediatric Clinical Illness Score ,PCIS）和儿童死亡风险评分（Pediatric Risk of Mortality Score ,PRISM ）对重症手足口病患儿病情进展的预测价值。【方法】选取于2010年1月至2013年6月入住本院重症监护室（ICU ）的符合重症手足口诊断标准的424名患儿。收集小儿PCIS和PRISM评分系统的相关生理参数及结局资料,通过受试者工作特征曲线（ROC）下的面积（AUC）来评估评分系统对并发症和结局的分辨力。【结果】死亡组患儿总住院天数和住IC U天数明显少于存活组患儿,且两者相比较差异有显著性（ P ＜0．05）。死亡组患儿肺水肿和肺出血的发生率明显高于存活组,且两者相比较差异有显著性（ P ＜0．05）。采用PCIS和PRISM评分来评价重症手足口病患儿病情发现,死亡组PCIS评分要明显低于存活组（Z＝－6．48,P ＝0．000）,死亡组PRISM 评分明显高于存活组（Z＝－7．39,P ＝0．000）,而且两评分系统存在相关性。PCIS和PRISM两评分系统分辨是否发生肺水肿、肺出血和死亡的AUC分别是0．74和0．78、0．82和0．87、0．83和0．87。【结论】PCIS、PRISM 均能够反映重症手足口病的危重程度,且相关程度高。两评分系统对重症手足口病发生严重并发症或者死亡的分辨力均到达可接受水平,且PRISM评分系统更优。     

PICU感染性休克患儿死亡危险因素的临床分析

目的：研究儿科重症病房（PICU）感染性休克患儿病死率及其死亡危险因素。方法回顾性分析118例感染性休克患儿资料,其中存活好转58例,死亡60例,采用单因素和多因素logistic回归分析两组临床资料的死亡危险因素。结果 PICU感染性休克患儿病死率高达50.8%;单因素分析结果显示,死亡组与成活组患儿在多器官功能障碍综合征（MODS）数目、低血压、PCIS评分、中性粒细胞数、紫癜或凝血障碍、入院24h尿量、血清白蛋白浓度、血乳酸浓度及需要使用机械通气支持治疗9个因素差异有统计学意义（P＜0.05）;多因素logistic回归分析显示,MODS数目、紫癜或凝血障碍、PCIS评分降低及需要机械通气支持治疗是感染性休克患儿死亡的独立危险因素（P＜0.05）。结论感染性休克患儿病死率较高,当其PCIS评分降低或发生MODS、紫癜、凝血障碍,或需要机械通气支持治疗时死亡风险更高,需早期检测治疗。     

重症患儿低C肽水平变化及其临床意义北大核心CSCD

目的：分析重症患儿血清C肽下降与病情危重度的关系。方法以2012－11-2013－06入住湖南省儿童医院儿科重症监护室（ PICU）且血清C肽下降的256例重症患儿为研究对象（C肽＜0．78 ng／mL）,C肽0．39-0．78 ng／mL为轻度降低组（n＝174）,C肽＜0．39 ng／mL为重度降低组（ n＝82）。监测入住PICU 24 h内、3 d、7 d的C肽、胰岛素和血糖,入院时检测电解质、白细胞、降钙素原、乳酸、红细胞压积、心肌酶、淀粉酶、肝肾功能相关指标及胰腺超声等,并记录与病情危重度及预后相关的指标。结果①低C肽患儿入院后C肽水平呈上升趋势,第3天稍高于正常,第7天恢复正常范围;②低C肽患儿入院后第3天胰岛素和血糖均升高并仍稍高于正常,第7天恢复正常范围;③C肽水平与WBC、PCT、乳酸呈负相关,与Ca2＋、氧合指数呈正相关（P＜0．01）;④C肽重度降低组白蛋白水平、小儿危重病例评分（PCIS）评分低于轻度降低组, ALT、AST、LDH和CK－MB水平高于轻度降低组（P＜0．05）;⑤C肽重度降低组PCIS评分低于轻度降低组（P＜0．05）;⑥死亡患儿中7例合并胰腺损伤,其平均C肽水平为（0．34±0．12）ng／mL。结论 C肽降低与炎症反应、缺血、缺氧等因素相关,重症患儿低C肽水平与胰腺损伤、病情严重程度、器官功能障碍和预后有一定关系。     

损伤控制性外科理论在合并腹部创伤的严重多发伤的应用分析

目的探讨损伤控制性外科理论在合并腹部创伤的严重多发伤中的临床应用。方法回顾性分析2009年1月-2012年12月4年来本院就诊的合并腹部创伤的老年患者60例,所有患者根据预后分为死亡组（n=10）和存活组（n=50）,入选患者按ISS评分分为3组：A组（n=25）16-24分、B组（n=23）25～34分、C组（n=12）〉35分,观察死亡和存活患者的颅脑损伤例数、ISS平均值和并发症例数,ISS评分与损伤部位数、手术部位数、确定性手术时间、输血量、住院时间、并发症和死亡率的关系。结果死亡组和存活组患者出现颅脑损伤和并发症例数比较差异有统计学意义（P〈0．05）;ISS评分平均值分别比较差异也有统计学意义（P〈0．01）。A、B和C3组ISS评分相比差异有统计学意义（P〈0．01）;3组确定性手术时间、输血量、住院时间随着ISS评分增加而明显增加,差异有统计学意义（P〈0．01）;3组出现并发症和死亡例数比较差异有统计学意义（P〈0．05）。结论ISS评分能对临床合并腹部损伤的多发伤患者的病情进行评估,并能指导治疗和评估预后,损伤控制性手术能明显降低老年创伤患者的术后并发症率和死亡率,改善患者预后。     

血浆氨基末端脑钠肽前体对脓毒症患者诊断及预后的意义

目的探讨氨基末端脑钠肽前体（NT-proBNP）对于脓毒症患者病情评估和预后判断的意义。方法将81例脓毒症患者根据病情严重程度,分为一般脓毒症组（39例）和重度脓毒症组（42例）。另外,根据28d生存情况将患者分为死亡组（13例）和存活组（68例）进行对比分析。采用一步免疫夹心法和酶联荧光分析技术测定脓毒症患者入院时的NT-proBNP浓度并进行急性生理学与慢性健康状况评分系统（APACHE）Ⅱ评分。结果重度脓毒症组患者血浆NT—proBNP浓度[（1488．43±1178．23）pg／m1]明显高于一般脓毒症组[（660．18±388．17）pg／ml],差异具有统计学意义（P〈0．01）。死亡组血浆NT—proBNP浓度及APACHEII评分均明显高于存活组,差异具有统计学意义（P〈0．01）。脓毒症患者入院时NT-proBNP浓度与APACHEII评分呈正相关（r=0．537,P〈0．01）。结论NT-proBNP对于脓毒症患者病情评估和判断预后具有一定应用价值。     

腹内压监测在危重病患者中的意义

目的研究腹内压（IAP）检测在危重病患者监测和治疗中的临床价值。方法分别分析比较危重病患者死亡组与存活组的IAP结果、急性生理及慢性健康评分（APACHEII）、脏器功能障碍综合征（MODS）评分结果,及计算腹内压正常组和增高组的APACHEⅡ评分和MODS评分及病死率。结果存活组入院即刻、第1天、第2天、第3天IAP值均低于死亡组,差异均有统计学意义（t分别=3．05、2．56、3．22、3．95,P均〈O．05）。监测腹内压死亡组与存活组的入院IAP及入院24hAPACHEII和MODS评分之间比较,差异均有统计学意义（t分别=3．05、2．56、3-22、3．95、3．07、2．89,P均〈0．05）。腹内压增高组与正常组入院24hAPACHEⅡ和MODS评分比较,差异均有统计学意义（t分别=2．29、2．16,P均〈0．05）;腹内压增高组的预后病死率与正常组比较。差异有统计学意义（x^2=3．88,P〈0．05）。结论腹内压升高与危重病患者的病情及预后有密切关系,对重症患者入院后进行腹内压测定有助于对病情的评估和预后的判断．     

5种评分方法在脓毒症相关性脑病预后评估中的作用北大核心CSCD

目的探讨儿童危重病例评分(PCIS)、儿童第三代死亡风险评分(PRISMⅢ)、儿童器官障碍评分2(PELOD-2)、儿童序贯器官衰竭评分(p-SOFA)及格拉斯哥昏迷评分(GCS)在SAE预后评估中的作用。方法回顾性分析2010年1月至2020年12月广东省人民医院儿科重症监护室(PICU)收治的82例脓毒症相关性脑病(SAE)患儿的临床信息,依据住院28 d结局分为存活组和死亡组,采用ROC曲线下面积(AUC)评价PCIS、PRISMⅢ、PELOD-2、p-SOFA和GCS评分对SAE的死亡预测作用;Hosmer-Lemeshow拟合优度检验评估各评分方法校准度。结果82例SAE截至入院28 d,存活72例,死亡10例,病死率12.20%,死亡组GCS[7(3,12)分vs.12(8,14)分]、PCIS[76(64,82)分vs.82(78,88)分]评分低于存活组,PRISMⅢ[14(12,17)分vs.7(3,12)分]、PELOD-2[8(5,13)分vs.4(2,7)分],p-SOFA评分[11(5,12)分vs.6(3,9)分]高于存活组(P均<0.05)。PCIS、PRISMⅢ、PELOD-2、pSOFA和GCS评分预测SAE预后的AUC分别为0.773(P=0.012,AUC>0.7),0.832(P=0.02,AUC>0.7),0.767(P=0.014,AUC>0.7),0.688(P=0.084,AUC<0.7),0.692(P=0.077,AUC<0.7);拟合优度检验示PCIS(χ^(2)=5.329,P=0.722),PRISMⅢ(χ^(2)=12.877,P=0.177)、PELOD-2(χ^(2)=8.487,P=0.205)、pSOFA(χ^(2)=9.048,P=0.338)、GCS(χ^(2)=3.78,P=0.848)。结论PCIS、PRISMⅢ和PELOD-2评分对儿童SAE预后具有良好预测能力,其中PCIS评分可以更为准确地对SAE预后预测的拟合效果进行评估。     

IL-6和IL-10在全身炎症反应综合征患者中的预警作用

目的 探讨IL-6与IL-10对全身炎症反应综合征患者病情和预后的判断作用。方法 将40例人住急诊ICU的SIRS患者分为多器官功能障碍综合征组（MODS组）和非MODS组，存活组和死亡组；选择健康体检者40例作为对照组。检测血清IL-6和IL-10浓度，并进行APACHEⅡ评分。结果 SIRS患者IL-6和IL-10浓度明显高于对照组（P〈0．01）；MODS组和死亡组IL-6浓度和APACHEⅡ评分分别明显高于非MODS组和存活组（P〈0．01）；MODS组和死亡组IL-10浓度分别与非MODS组和存活组比较差异无统计学意义（P〉0．05）。SIRS患者IL-6浓度与APACHEⅡ评分呈正相关（r=0．8813，P〈0．01），IL-10浓度与APACHEⅡ评分无相关性（r=0．0627，P〉0．05）。结论 在SIRS患者中早期检测血清IL-6浓度对患者病情和预后有判断作用，早期检测IL-10浓度对患者的预后没有判断作用。     

红细胞分布宽度预测心脏术后连续性肾脏替代治疗患者预后的价值

目的探讨红细胞分布宽度（RDW）对心脏手术后连续性肾脏替代治疗（CRRT）患者预后的预测价值。方法收集2012年1月到2013年6月因心脏手术后急性肾损伤（AKI）接受连续性静静脉血液透析滤过（CVVHDF）治疗的成年患者（既往无慢性肾脏病病史）,以28天为界分为存活组和死亡组,比较并分析心脏手术前及接受CRRT治疗首日2组患者的相关临床资料。以红细胞分布宽度（RDW）t〉15％或〈15％为界进一步分组,探讨RDW对患者死亡的预测效力和累积生存率的影响。结果本研究共纳入17例心脏术后AKI并接受CVVHDF治疗的患者。其中6例存活,11例死亡。死亡组RDW和SOFA评分显著高于存活组（P=O．048,0．014）。RDW和SOFA评分预测28天死亡的ROC曲线下面积（AUC）分别为0．765和0．848（P=0．024,0．0002）,但二者差异无统计学意义（P=0．541）。RDW≥15％患者28天死亡率显著高于RDW〈15％患者（P=0．038）。结论RDW可能是心脏术后AKI接受CRRT治疗患者的死亡预测因子。     

严重多发伤患者血清降钙素原水平变化与脏器功能不全的相关性

目的研究多发伤患者伤后血清降钙素原（PCT）的水平变化,并探讨其与创伤严重度ISS及危重程度APACHEII评分和脏器功能不全的相关性。方法测定26例多发伤患者伤后24h内的PCT水平,同时评定ISS、APACHEII分值及脏器功能不全的发生情况和死亡率。在此基础上进行统计分析,了解PCT水平变化及其与脏器功能不全和死亡率的相关性。结果（1）以ISS≤16为分组界限,多发伤患者两组之间PCT值比较,z=-2．129,P=0．042,差异具有统计学意义。（2）以APACHEII≤20为分组界限,多发伤患者两组之间PCT值比较,Z=-2．117,P=0.034,差异具有统计学意义。（3）以是否发生脏器功能不全为分组标准,两组之间PCT值比较,Z=-3．089,P=0．002,差异具有统计学意义。（4）以死亡或存活为分组标准,两组之间PCT值比较,z=-1．307,P=0．191,差异无统计学意义。（5）创伤后24h内的PCT水平与ISS评分、死亡或存活相关性无统计学意义（P〉0．05）,与APACHEII评分相关（P=0．033）,与OD相关（P=0．001）。（6）是否发生脏器功能不全,两组之间PCT值比较,差异具有统计学意义（X^2=14．282,P〈0．01）;当PCT≥10ng/ml时,脏器功能不全发生率明显增加（X^2=12．831,P〈0．01）。结论伤后24h内的PCT水平与APACHEII、脏器功能不全发生率密切相关,当PCT≥10ng／ml时,脏器功能不全发生率明显增加。     

应用段动脉阻力指数早期评价小儿肾积水手术后疗效

目的 探讨应用段动脉阻力指数(RI)、肾实质厚度(RPT)早期评价小儿肾积水手术疗效的临床可行性。方法 对32例接受手术治疗的单侧肾积水患儿于术前、术后2个月进行静脉尿路造影(IVU)检查,确定肾积水程度,术后恢复情况;手术前及手术后9天、2个月、6个月、1年分别进行彩超检查,测量患侧肾脏RPT、段动脉RI,并进行比较分析。结果 32例患儿中,其中14例为中度肾积水(中度肾积水组),18例为重度肾积水(重度肾积水组),术后2个月复查IVU均提示梗阻解除;患侧RPT均明显低于健侧(P均<0.01),且重度肾积水组明显低于中度肾积水组(P<0.01);中、重度肾积水组患侧肾段动脉RI均高于健侧(P均<0.01),重度肾积水组高于中度重度肾积水组(P<0.05);术后9天患侧RPT无明显变化(P均>0.05),中、重度组间差异有统计学意义(P<0.01);术后9天患侧肾段动脉RI均较术前减低(P均<0.05),中、重度肾积水组间患侧肾术后段动脉RI差异无统计学意义(P均>0.05)。结论 段动脉RI术后9天较术前减低,间接提示小儿肾积水患侧肾脏梗阻解除,可作为一种早期评价小儿肾积水手术后疗效的方法。     

急诊危重度指数在儿科急诊中的应用

目的 例证急诊危重度指数(ESI)在儿科急诊室的应用.方法 通过收集2006年7月至2010年8月,北京儿童医院国际部急诊21 904人次患儿的ESI分级资料,应用x2检验方法,回顾性对比分析医生和护士的分诊结果.结果 ESI容易掌握,护士分诊结果与医生矫正分诊结果有较好一致性.结论 ESI分诊系统适合儿科急诊分诊,能够迅速分检危重病例,有效利用临床资源.

Abstract：

Objective Demonstrate the implication of Emergency Severity Index (ESI) in pediatric emergency room (ER). Method ESI categories of 21 904 visitors to ER of Beijing Children's Hospital's international department were reviewed. SPSS statistic software was employed to compare the results of ESI categories by doctors and nurses separately using x2 analysis. Results There are highly consistency in ESI categories by doctors and nurses. ESI is an easy-learned and effective triage method. Conclusions ESI is capable in pediatric emergency room regarding recognizing serious cases and saving clinical resources.     

基于儿童早期预警评分构建的分级反应策略在儿科普通病房的应用价值研究

目的探讨基于儿童早期预警评分(PEWS)的分级反应策略在儿科普通病房的应用价值。方法选取2017年5-10月我院收治的325例入住儿科普通病房患儿,按入院先后时间分为观察组(163例)和对照组(162例)。对照组采用传统监护方案即依照医嘱执行监护;观察组采用Delphi专家函询所构建的PEWS分级反应策略进行干预。比较两组患儿PICU转入率、死亡率、平均住院日、人均住院总费用、患儿家属及医生的满意度。结果观察组在转入PICU率、平均住院日、人均住院总费用明显低于对照组(P<0.05),但患儿家属满意度及医生满意度高于对照组(P<0.05),两组死亡率差异无统计学意义(P>0.05)。结论基于PEWS评分构建的分级反应策略有较好的应用价值,能减轻患儿医疗费用,降低医疗风险,提高患儿家属及医生对护理工作的满意度,可促进科室人力资源配置弹性机制的建立。     

Development and implementation of a pediatric palliative care program

Palliative care, long-used in the adult setting, is new to the pediatric setting. Research indicates that palliative care reduces length of stay and use of aggressive end-of-life interventions, improves quality of life, and provides hope. It balances provision of coordinated care with building of family memories and preparation for the child's death with celebration of the child's life. We advocate implementation of pediatric palliative care in any hospital that cares for children. This article provides a model outlining critical steps and considerations for establishing a successful pediatric palliative care program.     

Evaluation of pediatric intensive care scoring systems

There is no report analysing pediatric severity scoring systems in British Intensive Therapy Units (ICUs). Two previously reported pediatric severity scoring systems, the Admission Physiologic Stability Index (APSI) and the Organ System Failure (OSF) score were evaluated for 151 patients. The APSI was higher for children who died than for those who lived (p<0.001). This difference reflected the sharp distinction between the APSI for chilren who left intensive care within 24 h and those remaining in ICU longer than 24h (p<0.001). For children remaining in ICU longer than 24 h, there was a large overlap of APSI scores, and the APSI did not discriminate between children in the overlap region who lived and those who died (p=0.054). There was underscoring of neurological patients; the APSI did not differentiate neurological patients whole lived and those who died (p>0.10). The OSF also underscored neurological patients. Increasing number of organ systems failed was associated with increasing mortality. In contrast to previous reports, however, the mortality rate was unaffected by whether the total number of systems failed simultaneously or non-simultaneously. There is still a need for a comprehensive yet simple pediatric scoring system for comparing the efficacy and outcome of pediatric intensive care in different ICUs in different countries.     

Enhancing the pediatric undergraduate nursing curriculum through simulation

Pediatric nursing courses have been affected by the increasingly limited amount of clinical placements and experiences for students. Securing clinical sites that provide well-rounded experiences in a limited amount of time is difficult. In addition, "teachable moments" can be lost on a busy unit due to variables outside of the control of the clinical faculty member, leading to a less than positive learning experience for students. A pediatric simulation curriculum was developed for the clinical rotation. This allowed students to begin their clinical experience better prepared and broadened their overall clinical experiences in a limited amount of time.     

小儿外科发展简史、特点和四川省小儿外科现状与展望

小儿外科作为一个年轻的临床专业,于第一次世界大战以后开始成为一个独立的学科,第二次世界大战之后,逐渐普及,并迅速发展。中国的小儿外科则是在新中国建立以后创建,在改革开放以后得到迅速发展。小儿不是成人的缩影,需要根据不同特点确定处理原则和方法。现在小儿外科服务范围包括从胎儿期到18周岁之内人群中的所有外科疾病患者,其中先天性畸形占相当大的比例,而许多需要及早发现、适时治疗,治疗的时机直接关系到疾病的预后。四川省的小儿外科在80年代后开始迅速发展,目前已从最初的少数几个中心,发展出多个中心,共同推动了治疗水平的提高。目前四川的社会经济发展需要组建更多、更高水平的妇儿中心,现在已出现可喜趋势。     

Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in Botswana

BackgroundWorldwide, 6.6 million children die each year, partly due to a failure to recognize and treat acutely ill children. Programs that improve provider recognition and treatment initiation may improve child survival.ObjectivesDescribe provider characteristics and hospital resources during a contextualized pediatric resuscitation training program in Botswana and determine if training impacts provider knowledge retention.Design/methodsThe American Heart Association's Pediatric Emergency Assessment Recognition and Stabilization (PEARS) course was contextualized to Botswana resources and practice guidelines in this observational study. A cohort of facility-based nurses (FBN) was assessed prior to and 1-month following training. Survey tools assessed provider characteristics, cognitive knowledge and confidence and hospital pediatric resources. Data analysis utilized Fisher's exact, Chi-square, Wilcoxon rank-sum and linear regression where appropriate.Results61 healthcare providers (89% FBNs, 11% physicians) successfully completed PEARS training. Referral facilities had more pediatric specific equipment and high-flow oxygen. Median frequency of pediatric resuscitation was higher in referral compared to district level FBN's (5 [3,10] vs. 2 [1,3] p = 0.007). While 50% of FBN's had previous resuscitation training, none was pediatric specific. Median provider confidence improved significantly after training (3.8/5 vs. 4.7/5, p < 0.001), as did knowledge of correct management of acute pneumonia and diarrhea (44% vs. 100%, p < 0.001, 6% vs. 67%, p < 0.001, respectively).ConclusionFBN's in Botswana report frequent resuscitation of ill children but low baseline training. Provider knowledge for recognition and initial treatment of respiratory distress and shock is low. Contextualized training significantly increased FBN provider confidence and knowledge retention 1-month after training.     

阿奇霉素治疗小儿肺炎的临床疗效

目的研究阿奇霉素治疗小儿肺炎的临床应用效果。方法选取2011年6月至2013年6月在汤阴县人民医院进行治疗130例的小儿肺炎患者,按随机分组原则分为实验组和对照组,两组在常规治疗的基础上,对照组加用红霉素治疗,实验组加用阿奇霉素治疗,1周为1个疗程。治疗1周后,比较两组治疗效果和用药后不良反应的发生情况。结果实验组患者治疗的总有效率为92.31%,明显高于对照组的80.00%;实验组用药不良反应发生率为24.62%,明显低于对照组的49.23%,差异有统计学意义（P〈0.05）。结论阿奇霉素治疗小儿肺炎效果显著,不良反应小,建议临床推广应用。     

Survey of complementary and alternative medicine in pediatric inpatient settings

ObjectivesWhile use of complementary and alternative medicine (CAM) is common in children, we know little about its use for hospitalized children. This survey measured the rate of CAM use, specific modalities used, and policies related to CAM use for hospitalized children.DesignAnonymous survey of hospitals in the Pediatric Research in Inpatient Settings (PRĪS) networkSettingHospitals in the PRĪS network.Main outcome measuresRate of overall and specific CAM modality use, including whether these modalities are provided, permitted, or prohibited, and presence of a written policy on CAM use.ResultsOf 99 sites queried, 22 responded. Of these, 82% of sites reported some CAM presence, and 63% reported official provision of CAM therapies. Freestanding children’s hospitals provided more modalities than other types of hospitals. There was no difference in number of modalities by geographic location. The most commonly provided CAM modalities were massage and biofield therapies. The most commonly prohibited modalities were inpatient placebos outside of research settings, medical marijuana, and inpatient homeopathic preparations. Only one site reported having a written policy on CAM use.ConclusionsAmong responding institutions, the most reported some CAM presence with a wide variety of CAM modalities provided and permitted. Written institutional policies on CAM were rare.