我院儿科ICU休克116例临床分析

目的 调查近年来休克的流行病学,临床特点和休克死亡相关因素,探讨小儿休克临床分型。方法：对１９９６年１月￣１９９７年１２月入院ＰＩＣＵ时或住院期间发生休克的病例进行回顾性临床分析。结果 ５９４例中１１６例发生休克,休克患病率１９．５％,死亡４９例,病死率４２．２％。外因,内因和医源混合因素引起的休克占７５．９％。休克死亡多因素变量分析显示：休克〉８小时,脏器低灌注〉１２小时,小儿危重病例评分（ＰＣ     

应用危重病例评分法预测PICU患儿的预后

目的　应用国内儿科危重病例评分法（ＰＣＩＳ）评价儿科ＩＣＵ（ＰＩＣＵ） 患儿的病情危重度,预计病死风险率,探讨死亡相关因素。方法　对１９９６ 年１ 月～１９９７ 年１２ 月ＰＩＣＵ 的６５０ 例住院患儿进行ＰＣＩＳ评分和资料分析。用ＳＡＳ统计软件,进行单因素分析和逐步Ｌｏｇｉｓｔｉｃ 回归筛选变量分析,根据评分值建立病死风险率预计公式１ ,并观察预计模型的准确性和对个体预后的判断能力。结果　死亡９７ 例,病死率１４．９ ％ 。评分值、基础疾病、心跳呼吸骤停、脏器衰竭数目、院内感染、住院日数和是否来源于其他病房与死亡密切相关（ Ｐ均＜ ０．０５） 。死亡独立危险因素为心跳呼吸骤停和脏器衰竭数目。根据入ＰＩＣＵ最初２４ 小时的最低评分值建立病死风险率预计公式：Ｌｏｇｉｔ（ｐ） ＝ ８．３９４ － ０．１２３ ×评分值,敏感度、特异性和阳性预计值分别为４３．３％ 、９４．９％ 和７７．２％ 。结论　（１）ＰＣＩＳ适用于ＰＩＣＵ 评估患儿病情危重度和个体病死风险率。（２）所得预计模型适合ＰＩＣＵ 近期应用。（３） 防止和减少心跳呼吸骤停的发生是降低病死风险率的关键。     

中国儿科重症监护室近10年发展情况调查分析

目的 了解2000至2009年我国重症监护室(ICU)的发展情况与现状。方法 对全国内地有中华医学会儿科学分会急救学组及急诊医学分会儿科学组成员的35家医院进行问卷调查,收集2009年1至11月资料并与2000年27家儿童医院调查数据（B组）进行比较。结果 33(94.3％)家医院作复,其中25家为儿童专科医院（A1组）,8家综合医院儿科（A2组）。ICU[儿科重症监护室( PICU)和新生儿重症监护室(NICU)]床位占医院儿科床位比例A1组较B组(6.9％vs.5.8％)增加1.1个百分点。ICU医生床位比A1组和B组分别为0.5：l和0.75:1,护士床位比分别为1.17:1和1.38:1。监护仪与床位比A1组为1.44:1,B组为0.74:1,有创呼吸机与床位比A1组为0.64:1,B组为0.46:1。拥有血气分析仪、可作床旁X-线摄片与超声检查的医院所占比例,A1组和B组分别为100％( 25/25):60％( 16/27),96％( 24/25):70％( 19/27)及88％ (22/25):30％( 8/27)。A1组和B组开展肺表面活性物质(Ps)治疗分别为96％ (24/25):48％ (13/27)、持续血液净化(CBP) 80％( 20/25)：22％ (6/27)、高频通气(HFV) 84％ (21/25):37％( 10/27)。A1组开展ECMO有20％(5/25),B组为0。在ICU（PICU和NICU）,A1组和B组有创机械通气治愈好转率分别为77.5％(6393/8245)：63.4％ (809/1276),B组低于A1组(P＜0.001)。A1组和B组1～1.5 kg早产儿治愈好转率分别为88％ (2183/2482)：75.1％( 531/707);＞1.5 ～2.5者分别为93.7％(6836/7296):84.1％(1890/2247),B组均较A1组低(P＜0.01)。A1组和A2组分别对12 659和1392例PICU患儿作了危重病例评分,其中非危重病例两组分别为3616例（占28.6％）和639例（占45.9％）,A1组低于A2组(P =0.000)。床位使用率PICU A1组和A2组分别为127.1（103.3～186.0）和90.91 (71.0～126.0),NICU两组分别为138.0(83.8～290.5)和108.9（90.7～128.0）。结论两次所调查的医院分布地域广、ICU成立较早,其前后10年状况大致可代表我国儿科ICU的发展与现状,特别是PICU。ICU的设备、技术、治疗结果均有显著提高,但专业医护人员匮乏,床位使用率及收治非危重患儿比例过高等问题,需受重视。     

儿科重症监护病房患儿的病毒病原监测及其临床意义

目的 探讨儿科重症监护病房患儿的病毒病原谱特点及其临床意义.方法 收集汕头大学医学院第二附属医院儿科重症监护病房患儿的咽拭子标本349份,同时收集该349例病例中因发热抽搐而需行腰椎穿刺术的患儿脑脊液标本130份,选取社区健康体检儿童87份咽拭子作为健康对照组.应用多重PCR技术,对咽拭子和脑脊液标本进行16种呼吸道病毒检测,同时应用荧光实时PCR技术,对脑脊液标本检测13种脑炎相关病毒,并对阳性病例的临床资料进行分析.结果 349份咽拭子标本中,病毒阳性209例(59.9％),其中鼻病毒117例,呼吸道合胞病毒60例,流感病毒A 20例,腺病毒10例,副流感病毒-3 6例,博卡病毒6例,流感病毒C5例,副流感病毒4 4例,冠状病毒HJYl/OC43 4例,流感病毒B3例,WU多瘤病毒3例,副流感病毒-l 2例,偏肺病毒2例,冠状病毒NL63/229E l例.87名健康儿童呼吸道病毒检测均为阴性.130例留取脑脊液标本的病例中,最后诊断为病毒性脑炎58例,病毒阳性22例(37.9％),其中肠道病毒通用型14例,巨细胞病毒3例,腮腺炎病毒2例,柯萨奇A16型l例,单纯疱疹病毒1例,鼻病毒1例.349例入选病例中,咽拭子和脑脊液病毒检测总阳性率为63.3％ (221/349).同一患儿检测到病毒混合感染45例(12.9％),占所有病毒阳性病例的20.4％.混合感染率最高为WU多瘤病毒(100％,3/3)和人偏肺病毒(100％,2/2).病毒阳性病例中,年龄＜6个月病毒感染率最高(72.2％),男性(148例)明显多于女性(73例).病毒阳性组中非危重病例少于病毒阴性组,而极危重病例则多于阴性组.结论 病毒是儿童重症感染性疾病的重要病原体,病毒感染可能导致病情加重,全面监测儿科重症监护病房病毒病原谱,对于提高感染性疾病诊断的准确性及治疗的针对性具有重要的临床意义.     

The profile and outcome of patients admitted to a pediatric intensive care unit

The records of all admissions to a 6-bed pediatric intensive care unit (PICU) over a period of 6 years were reviewed. The age, diagnosis, clinical service provided, duration of stay and outcome were recorded. Of the 3025 children admitted, 2092 (69.2%) were males. Neonates constituted 13.1% (400) and infants 57.1% (1727) of total admissions. The duration of stay ranged from 6 hours to 46 days, and 61 patients stayed for longer than 13 days (long-stay patients). The most common cause for admission was septicemia, seen in 459 patients (14.8%); 418 (13.8%) children had congenital heart disease, 407 (13.5%) lower respiratory tract infections (LRTI) and 261 (8.6%) meningitis. The most common conditions necessitating long-stay in the PICU were meningitis (20%), Landry-Guillain-Barre syndrome (16.6%), acute renal failure (20%), and septicemia (16.6%). There were 721 deaths giving a mortality of 23.5%. Of these 134 (18.6%) were due to septicemia, 103 (14.2%) due to congential heart disease, 77 (10.6%) due to meningitis and 55 (7.6%) due to LRTI. The highest case fatality rate was seen with encephalitis (52.6%), followed by hepatic coma (51.3%), malignancies (43.2%), septicemia (29.1%) and meningitis (29.5%). The mortality was lower (9.8%) in long-stay patients than in short-stay patients (24.6%). There was gradual increase in proportion of cases requiring interventions including artificial ventilation (1% to 35%), peritoneal dialysis (1.5% to 11%), insertion of central venous pressure lines (0 to 10%), over the last 6 years. The comparison of case fatality rates before and after the PICU was made a functionally independent unit eleven months ago, reveals a declining trend for certain diseases including LGB syndrome (22.5% to 0%) (p<0.02), dengue hemorrhagic fever (44% to 9%) (p<0.02), meningitis (34% to 20%). renal failure (17% to 10%), encephalitis (55% to 26%). The ventilator survival increased from 22% to 42% (p<0.001).     

Assessment of the performance of the Pediatric Index of Mortality 2 (PIM2) among Egyptian pediatric patients admitted to the intensive care

BackgroundMortality prediction models are useful in pediatric intensive care units (PICUs) as risk assessment tools and as a benchmark for the quality of care.ObjectivesTo assess the performance of the Pediatric Index of Mortality 2 (PIM2) in terms of calibration and discrimination between survivors and non-survivors among pediatric patients.MethodsThis is a cohort prospective study including 317 pediatric patients admitted to two PICU settings in a tertiary care hospital in Egypt over a period of one year (from June 2012 till June 2013). Collected data included personal characteristics, hospital data, diagnosis, outcome and variables included in PIM2 scoring.ResultsNon-survivors constituted 8.5%. Most common diagnosis was respiratory diseases (47.9%). Only CNS morbidities (11.7% of survivors versus 37% of non-survivors, P = 0.001) and a higher PIM2 score (2.39 ± 5.49 in survivors versus 41.38 ± 36.06 in non-survivors, P = 0.001) were associated with increased risk of non-survival. The area under the curve (AUC) for PIM2 is 0.796 (95% CI 0.675–0.916), P < 0.001. The Hosmer–Lemeshow goodness-of-fit was 2.850, 8 df, P = 0.943. PIM2.ConclusionThe calibration and the discriminative ability of PIM2 scoring system aiming to distinguish survivors from non-survivors are satisfactory for this sample of pediatric patients. PIM2 is easily calculated and is freely available. Thus, this tool provides a good incentive for ICU settings in Egypt for admission of high risk patients in the light of the limited PICU bed complement capacity in relation to the demands.     

End-of-life practices in seven Brazilian pediatric intensive care units.

OBJECTIVE: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). DESIGN: Cross-sectional multicenter retrospective study based on medical chart review. SETTING: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in S?o Paulo (southeastern region), and three in Salvador (northeastern region). PATIENTS: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. INTERVENTIONS: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. MEASUREMENTS AND MAIN RESULTS: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. CONCLUSIONS: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.     

Nosocomial infections in pediatric intensive care units

Nosocomial infections are a significant problem in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 6–8%. The common nosocomial infections in PICU are bloodstream infections (20–30% of all infections), lower respiratory tract infections (20–35%), and urinary tract infections (15–20%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Most often the child had endogenous flora, which may be altered because of hospitalization, are responsible for the infections. The common pathogens involved areStaphylococcus aureus, coagulase negativestaphylococci, E. coli Pseudomonas aeruginosa, Klebsiella, enterococci, andCandida. Nosocomial pneumonias predominantly occur in mechanically ventilated children. There is no consensus on the optimal approach for their diagnosis. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. The diagnostic criteria have been discussed in the review. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; handwashing, judicious use of interventions, and proper asepsis during procedures remain the most important practices.     

我院儿童加强医疗病房脑死亡发生率及临床特点分析

目的了解脑死亡在儿童加强医疗病房（ＰＩＣＵ）的发生率并分析其特殊临床表现。方法对１９９４年３月～１９９８年３月ＰＩＣＵ确诊的１４例脑死亡患儿的临床资料进行总结分析。结果脑死亡在ＰＩＣＵ的发生率为０．８７％（１４／１６０４），占总死亡患儿数的１２．１％。原发病以颅内感染为主。中枢性尿崩症、高血糖、低二氧化碳分压的发生率分别为７３％（８／１１）、４３％（６／１３）和５０％（７／１４），两种症状同时出现占６２％（８／１３），三联征同时出现占２７％（３／１１）。结论该院ＰＩＣＵ脑死亡发生率为０．８７％。中枢性尿崩症、高血糖、低二氧化碳分压是部分脑死亡患儿重要的临床表现。     

新生儿重症监护病房的院内感染638例分析

目的调查NICU院内感染的发生情况,探讨其危险因素,为院内感染的防控提供依据。方法对我科2003年5月至2004年12月,住院的638例新生儿进行院内感染的监控,并进行分析和总结。结果638例新生儿中74例发生88次院内感染,发生率为11．6％;住院日相关的院内感染率为14．9／1000NICU病例一天;导管相关血行感染率为18／1000血管内导管一天（2／111）;呼吸机相关肺炎发生率为63．3／1000机械通气一天（15／237）;平均开始出现感染时间（7．98±4．58）d。发生院内感染者比未感染者的胎龄及出生体重低、住院时间延长。新生儿发生院内感染的危险因素包括胃肠外营养、出生体重≤1500g及呼吸机治疗等（P〈0．05）。感染部位中,以肺炎占首位（45．4％）。院内感染病死率为4．1％。入院后有细菌定植者较无定植者院内感染率高（Х^2=79．7,P〈0．001）。结论充分了解NICU中新生儿发生院内感染的高危因素、尽量减少肠外营养及侵袭性操作的次数和时间、明确NICU中患儿个体细菌的定植情况将有助于控制院内感染并对临床合理用药提供参考。     

胆道闭锁患儿肝移植术后的监护与治疗

目的 回顾分析22例胆道闭锁患儿(23例次,其中1例行再次肝移植)肝移植术后的重症监护管理经验,探讨并发症的发生率以及病原菌与患儿并发症预后之间的联系.方法 统计分析22例平均体重＜8.8 kg的婴幼儿在ICU的相关临床资料,包括药物的使用情况(肾上腺素能激动剂、抗高血压药、利尿剂、镇静止痛药)及主要并发症(排异反应11例,外科并发症16例,感染18例)的诊断、评估及治疗,其中抗生素的选用主要根据药敏试验结果决定.结果 最常见的术后并发症包括感染(18例)、消化道出血(3例)、血管并发症(4例).1例死于原发性无功能肝,11例出现排异反应.最常见的病原微生物包括表皮葡萄球菌(7例),不动杆菌属(6例),铜绿假单胞菌(7例).ICU平均住院时间为10 d,机械通气平均时间37.6 h.多巴酚丁胺、前列腺素E1、多巴胺的平均使用时间分别为3.3 d,7.5 d,8.8 d.术后胃肠外营养的平均起始时间为12 h,进食起始时间平均72 h.结论 术后监护是保证婴幼儿肝移植成功的关键之一.

Abstract：

Objective To summarize experience of pediatric intensive care and explore the incidence of complications, the involved pathogens among liver recipients to determine the effective strategies for preventing complications. Methods Between June 2006 and July 2009, 35 children under the age of 14 yr received 35 liver transplantations (LTs) performed at the center. A retrospective review of 22 infants weighing 8. 8 kg or less underwent 23 transplants was conducted. Indication for transplantation was biliary atresia. Central venous pressure and arterial blood pressure were monitored continuously and fluid monitoring was performed every 2 hours in the first postoperative week. Blood loss, ascites, and intraoperative transudate loss were primarily replaced with 5% albumin and crystalloids to maintain a central venous pressure between 4 and 6 cm H2O. Oral food intake was allowed as soon as possible. To identify vascular or biliary complications, liver doppler ultrasound was performed intraoperatively immediately after reperfusion and after closure of the abdominal wall and postoperatively, twice daily during the first week after surgery.Immunosuppression was initially cyclosporine based, in combination with steroids. Cyclosporine was begun one day prior to transplantation at a dose of 10 mg/( kg · d) divided into two doses, except for cases with hepatic encephalopathy and severe infection. The subsequent doses were adjusted on the basis ofrecommended trough blood concentrations at different stages. Steroids were eventually discontinued at a time point exceeding 6 months after transplantation. The diagnosis of rejection was confirmed by histology on needle biopsy specimens. Acute graft rejection episodes were treated with a 3-day scheme of Ⅳ methylprednisolone 10 mg/( kg · d) followed by recycling doses during the following 3 days (7.5, 5 and 2. 5mg/(kg · d). Results The most common postoperative complications were infections (18 cases),gastrointestinal bleeding (3 cases), and vascular complications (4 cases). Rejection occurred in 25% of patients. There was one perioperative death from primary graft non-function. The most common isolated bacteria of the pathogen spectrum were Staphylococcus epidermidis. The median length of stay (LOS) in the PICU for 22 patients (23 transplants) was 10 days ( range 5-21 ) and the mean length of stay in the hospital was ( 18.5 ± 116) days ( range, 11-48 days). Mean requirement for artificial ventilation was 37.6 h. Mean use of dobutamine, prostaglandin E1 and dopamine was 3.3, 7.5 and 8.8 days, respectively.Preoperatively, 3 children had gastrointestinal bleeding, 18 had ascites, 2 had encephalopathy, 22 had jaundice, and 16 had coagulopathy. There were multiple early operative complications in these infants,including one graft with primary non-function (4. 5% ). Two patients (9. 1% ) returned for a total of three times for gastrointestinal bleeding or intra-abdominal hematoma. Three patients (13.6%) had early postoperative intestinal perforations related to adhesions or enterotomy, one was associated with a bowel obstruction. There were 26 episodes of bacterial or fungal infections in 18 (81.8%) patients in the early postoperative period, and infection was the direct/contributing cause of death in one infant. These infections included pneumonia, intra-abdominal abscess or sepsis. All of the bacterial and fungal infections were successfully treated with the appropriate antibacterial and antifungal agents, except for one patient who developed overwhelming sepsis after small bowel perforation. Four (18.2%) patients developed five episodes of acute allograft rejection during the first 15 days after LT. Three of the four patients who developed rejection were transplanted before 2007. All episodes of rejection were treated successfully with intravenous steroid pulse and optimization of cyclosporine levels or FK506 conversion. Of the 20 survivors beyond the perioperative period, two cases ( 10% ) had hypertension requiring therapy. Conclusions Liver transplantation in infants with biliary atresia appears technically demanding but acceptable. There should be essentially no age or size restriction for infants and transplantation can be performed with good outcome,although the frequency of complications is much higher than that seen in older children. The improvement in medical and nursing expertise in this group of very sick infants is based on judicious preoperative donor and recipient selection, meticulous surgical technique (vascular reconstruction and abdominal closure ),immediate detection and prompt intervention of complications, and keen postoperative surveillance, which reflect a learning curve for both the technical aspects of liver transplantation and post-operative care of these very small patients in our institution. Liver transplantation for infants can be technically challenging.     

Demographic profile and outcome analysis of a tertiary level pediatric intensive care unit

Objective : To study the profile and outcome of children admitted to a tertiary level pediatric intensive care unit (PICU) in India.Methods : Prospective study of patient demographics, PRISM III scores, diagnoses, treatment, morbidity and mortality of all PICU admissions.Results : 948 children were admitted to the PICU. Mean age was 41.48 months. Male to female ratio was 2.95:1. Mean PRISM III score on admission was 18.50. Diagnoses included respiratory (19.7%), cardiac (9.7%), neurological (17.9%), infectious (12.5%), trauma (11.7%), other surgical (8.8%).196 children (20.68%) required mechanical ventilation. Average duration of ventilation was 6.39 days. 27 children (30.7 children /1000 admissions) had acute respiratory distress syndrome. Gross mortality was 6.7% (59 patients). PRISMIII adjusted mortality was directly proportional to PRISMIII scores. 49.5% of nonsurvivors had multiorgan failure. Average length of PICU stay was 4.52 +/−2.6 days. Complications commonly encountered Were atelectasis (6.37%), accidental extubation (2%), and pneumothorax (0.9%). Incidence of nosocomial infections was 16.86%.Conclusion : Our data appears to be similar with regards to PRISMIII scores and adjusted mortality, length of the PICU stay, and duration of ventilation, to previously published western data. Multiorgan failure remains a major cause of death. As expected, Dengue and malaria were common. Incidence of nosocomial infections was somewhat high. Interestingly, more boys got admitted to the PICU as compared to girls. Clearly more studies are required to assess the overall outcomes of critically ill children in India     

儿童重症监护病房侵袭性真菌感染38例临床分析

目的：探讨儿童重症监护病房（PICU）侵袭性真菌感染（IFI）的临床特征,为其有效防治提供依据。方法：回顾性分析38例IFI患儿的临床特征及治疗转归情况。结果：38例患儿中,以呼吸道感染最多见（89%）;感染前均有较严重的基础疾病,且使用过多种抗生素,其中碳青霉烯类抗生素使用率高达95%;47%患儿曾全身激素治疗;所有患儿均有侵入性操作史,其中47%患儿接受过气管插管及机械通气治疗;所有患儿临床症状及体征不典型,影像学检查无特异性。真菌培养共检出致病真菌56株,以白色念珠菌为主（41%）,其次为曲霉菌（25%）和毛霉菌（20%）;所有患儿及时予以高效抗真菌药物治疗,治愈15例,好转16例,有效率为82%,不良反应发生率为16%。结论：呼吸道为最常见IFI感染部位;白色念珠菌为主要病原;多数患儿有严重基础疾病、广谱抗生素及糖皮质激素的使用史和侵入性操作史;早期诊断、及时使用高效抗真菌药物可改善预后。     

Oral itraconazole in treatment of candidemia in a pediatric intensive care unit

Objective: To examine efficacy of itraconazole in the treatment of candidemia in critically ill children.Methods: We studied retrospectively cases of candidemia seen consecutively in our Pediatric Intensive Care Unit (PICU) over three and half year.Candida isolates from those patients included.Candida albicans- 19, C.tropicalis-31,C. guillermondii- 9,C.krusei- 4 andC. glabrata-1Results: Of the 64 patients, 48 (75%) had symptoms suggestive of septicemia and 16 had no symptoms suggestive of septicemia. No antifungal therapy was given to asymptomatic patients; they recovered from candidemia without development of any sequelae. Of the 48 symptomatic patients 11 died before results of fungal culture became available and antifungal therapy could be started. Thirty seven patients were treated with itraconazole (10 mg/kg/day orally or through gastric tube). Seven (18.9 %) of 37 patients died, 3 within first week of antifungal therapy. Thirty (81%) patients recovered; microbiological cure was noted on average by day 14 (range 4–30 days). The mean ±SD duration of therapy in patients who responded was 24 ±7 days (range 21–42 days). None had any major side effect.Conclusion: We conclude that oral itraconazole may be effective in treatment of candidemia in children in a PICU where non-C.albicans Candida species constituted majority (70%) of allCandida isolates.     

No resuscitation orders and withdrawal of therapy in French paediatric intensive care units

Objective: To determine the incidence of different modes of death in French paediatric intensive care units and to compare patients' characteristics, including a severity of illness score (Paediatric Risk of Mortality: PRISM score) and prior health status (Paediatric Overall Performance Category scale), according to the mode of death. Design: A 4-month prospective cohort study. Setting: Nine French multidisciplinary paediatric intensive care units. Patients: All patients who died in PICUs, except premature babies. Main results: Among 712 admissions, 13% patients died. Brain death was declared in 20%, failure of cardiopulmonary resuscitation occurred in 26%, do-not-resuscitate status was identified in 27%, and withdrawal of supportive therapy was noted in 27%. The PRISM score and the baseline Paediatric Overall Performance Category were not different between the four groups. Brain-dead patients were older than those in whom a do-not-resuscitate order and withdrawal of therapy were made (median age 81 vs 7 and 4 months). Conclusions: Decisions to limit or to withdraw supportive care were made for a majority of patients dying in French paediatric intensive care units. Chronic health evaluation and severity of illness index are not sufficient to describe dead-patient populations.     

新生儿重症监护室内假丝酵母菌败血症感染九例分析

目的分析新生儿重症监护室内假丝酵母菌败血症的临床特点。方法总结9例确诊病例的临床特征,进行易感因素分析。结果9例均为早产儿,极低出生体重儿6例。9例真菌感染前全部接受广谱抗生素治疗及静脉营养,8例留置中心静脉导管（ PICC, percutaneous inserted central catheter）,3例曾机械通气。生后8～22d出现呼吸暂停、灌注差、反应差等症状,7例血小板减少,7例C反应蛋白升高。血培养白色假丝酵母菌1例,近平滑假丝酵母菌2例,季也蒙假丝酵母菌6例,5例PICC导管尖端培养和血培养同时阳性,且为同一菌株。9例均接受抗真菌及对症支持治疗,6例治愈,1例放弃治疗自动出院,2例死亡。结论新生儿假丝酵母菌败血症的高危因素包括早产、留置PICC、长期应用广谱抗生素、机械通气等,症状常不典型,可伴有血小板减少,C反应蛋白轻中度升高等,早期积极治疗预后较好。