205例脓毒症患儿生存分析

目的了解儿童脓毒症的生存情况,探讨影响其预后的相关因素。方法回顾性分析205例脓毒症患儿的临床资料,包括性别、年龄、90 d内生存情况等。结果 90 d生存率78.0%(Life Table法),发病后7～25 d死亡风险最高。死亡患儿并发脓毒性休克(shock)、急性肺损伤(ALI)/呼吸窘迫综合征(ARDS)和多器官功能障碍(MODS)的比例高于存活患儿,差异有统计学意义(P<0.05);死亡患儿的年龄、入PICU时及最危重时的儿童危重病例评分(PCIS)、收缩压(SBP)、舒张压(DBP)、血清白蛋白(ALB)和血小板计数(PLT)均低于存活患儿,而机械通气治疗时间长于存活患儿,差异均有统计学意义(P<0.05)。入选死亡因素多元Cox比例风险回归方程的变量为年龄(RR=0.426)、MODS(RR=4.732)、ALI/ARDS(RR=4.269)、最危重时的PCIS(RR=0.186)、机械通气时间(RR=0.159)和ALB(RR=0.507)。方程的受试者工作特征曲线(ROC)下面积为0.847(95%CI:0.787～0.908),判定死亡的灵敏度91.30%,特异度65.40%,一致率71.22%(Kappa=0.146,P=0.001)。结论儿童脓毒症病死率高,年龄、MODS、ALI/ARDS、最危重时PCIS和ALB是影响其预后的强相关因素。     

小儿严重脓毒症并发多器官功能障碍综合征的研究

目的 小儿脓毒症是PICU的常见疾病,具有较高的病死率.本研究旨在了解小儿脓毒症的临床特点及转归,探寻儿童严重脓毒症的死亡危险因素.方法 分析2008年1月至12月收入我院PICU的脓毒症病例,对严重脓毒症患儿作单因素分析,并建立Logistic回归模型,探寻儿童严重脓毒症的死亡危险因素.结果 纳入脓毒症患儿103例,病死率16.5%.严重脓毒症45例,其死亡危险因素是PRISM Ⅲ评分(OR 1.502;95%CI 1.131～1.995)和病程中外周血血小板计数最高值(OR 0.991;95%CI0.982～1.000).小儿严重脓毒症伴随1、2、3、4个及4个以上脏器功能障碍的病死率分别为10.0%、11.1%、44.4%、68.8%,差异具有非常显著性(P＜0.001).最常受累的是心血管系统(75.6%)和呼吸系统(66.7%),严重脓毒症伴发MODS死亡危险因素是呼吸系统(OR 23.179;95%CI2.095～256.522)和肾脏(OR 9.637;95%CI 1.698～54.703)功能受累.结论 小儿严重脓毒症的死亡危险因素是PRISM Ⅲ评分和病程中外周血血小板计数最高值.小儿脓毒症合并MODS提示预后不良,其病死率与发生功能障碍的脏器数目呈正相关,呼吸系统和肾脏功能受累是儿童脓毒症死亡的危险因素.     

Procalcitonin Biomarker Kinetics to Predict Multiorgan Dysfunction Syndrome in Children With Sepsis and Systemic Inflammatory Response Syndrome

Background:

Procalcitonin (PCT) kinetics is a good prognosis marker in infectious diseases, but few studies of children sepsis have been performed.

Objectives:

The aim of our study was to examine kinetics of procalcitonin, to evaluate its relationship with severity and to analyze its usefulness in the prediction of multiorgan dysfunction syndrome (MODS).

Patients and Methods:

Prospective observational study in an 8-bed pediatric intensive care unit of a university hospital. Sixty-two children aged 0-19 years with systemic inflammatory response syndrome or septic states. The degree of severity was evaluated according pediatric logistic organ dysfunction (PELOD) score. Blood tests to determine levels of PCT were taken if the patients had the criteria of systemic inflammatory response syndrome or sepsis. The serum to determine levels of PCT in control group has been taken from patients undergoing elective surgery.

Results:

Higher values of PCT were identified in patients with PELOD score 12 and more compared to those with PELOD < 12 (P = 0.016). Similarly, higher PCT values were found in patients who developed MODS in contrast to those without MODS (P = 0.011). According to ROC analysis cut-off value of 4.05 ng/mL was found to best discriminate patients with PELOD < 12 and PELOD ≥ 12 with AUC = 0.675 (P = 0.035). Effect of procalcitonin levels on mortality was not demonstrated.

Conclusions:

Levels of procalcitonin from day 1 to day 5 are related to the severity and multiorgan dysfunction syndrome in children.     

小儿脓毒症并腹内高压的危险因素分析

目的：探讨小儿脓毒症并腹内高压（IAH）的危险因素, 为早期诊断、及时干预治疗提供理论依据。方法：采用膀胱测压法对119例脓毒症患儿进行腹内压检测,根据腹内压检测结果将患儿分为腹内压正常组(对照组,n=80)与IAH组(n=39)。采用单因素和非条件logistic回归分析对两组患儿的临床资料进行分析,以调查脓毒症患儿并发IAH的危险因素。结果：单因素分析发现小儿危重病评分（PCIS）、降钙素原（PCT）、PaCO2、血清乳酸值及肠道/腹腔感染、腹水、胃肠功能障碍、机械通气、休克和多脏器功能不全（MODS）的发生比例在IAH和对照组间比较差异均具有统计学意义（P<0.05）。Logistic回归分析显示PCIS降低、MODS、休克、胃肠功能障碍和腹水是脓毒症合并IAH的主要危险因素。结论：PCIS降低、MODS、休克、胃肠功能障碍和腹水的脓毒症患儿, 有发生IAH的可能, 应重点监测,以早期诊断并予及时干预治疗。     

Thyroid hormone levels and their relationship to survival in children with bacterial sepsis and septic shock

OBJECTIVES: Reported studies have showed alternations of thyroid hormones in critical illness mostly in adults and some in children. In this study, we aimed to measure thyroid hormone levels in children with sepsis and septic shock and investigate the relationship of these hormones with clinical state and survival. PATIENTS AND METHODS: Thyroid hormone levels of children with sepsis and septic shock, and age- and sex-matched controls were measured. RESULTS: There were 51 children in sepsis (group S), 21 children in septic shock (group SS) and 30 in the control (group C) group. Total triiodothyronine (TT3) levels were (nmol/l): 0.91 +/- 0.22, 0.64 +/- 0.23, 2.11 +/- 0.59; free triiodothyronine (FT3) (pmol/l): 0.027 +/- 0.006, 0.018 +/- 0.007, 0.049 +/- 0.010; total thyroxine (TT4) (nmol/l): 100.62 +/- 21.93, 65.79 +/- 19.35, 109.65 +/- 19.35; free thyroxine (FT4) (pmol/l): 18.06 +/- 3.87, 10.32 +/- 1.29, 19.35 +/- 3.87; and thyroid stimulating hormone (TSH) (mIU/ml): 5.0 +/- 2.0, 4.8 +/- 2.4, 5.2 +/- 3.0, in children with sepsis, septic shock, and controls, respectively. The TT3, FT3, TT4, and FT4 levels of group SS were significantly lower than those of groups S and C. The TT3 and FT3 levels of group S were lower than in group C, but there was no significant difference between TT4, and FT4 levels of groups S and C. TSH levels were slightly decreased in both sepsis and septic shock, but the difference was not significant. Eleven (21.6%) children with sepsis and 15 (71.4%) children with septic shock died (p < 0.001). The levels of TT3, FT3, TT4 and FT4 were markedly lower in non-survivors of groups S and SS compared to survivors (p < 0.001). CONCLUSIONS: These changes in the hypothalamo-pituitary-thyroidal axis may suggest a possible prognostic value of thyroid hormone levels in children with sepsis and septic shock. To the best of our knowledge, this report is the first study to compare thyroid hormone levels in a large number of patients with sepsis and septic shock with those in healthy controls in childhood.     

Epidemiology and Outcome of Sepsis in a Tertiary Care PICU of Pakistan

Objective

To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital.

Methods

Retrospective review of children 1?mo to 14?y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression.

Results

In 2?years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18?mo (IQR 6–93?mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2–144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6–4.0) and the need for?>?2 inotropes (Adjusted OR 3.5, 95% CI 1.3–9.2) were independently associated with mortality due to sepsis.

Conclusions

The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.     

儿童脓毒症生物标记物的研究进展

脓毒症是机体对感染的反应失调而导致危及生命的器官功能障碍,是当今危重病医学所面临的焦点和难点问题.目前世界范围内儿童脓毒症的发生率仍居高不下,若治疗不及时可发展成脓毒性休克、多器官功能障碍综合征,严重威胁人类健康.因此脓毒症的早期识别、诊断、治疗对降低病死率有重要意义.而生物标记物在脓毒症的早期诊断、病情及预后判断,疗效评估中发挥重要作用.本文就近年来脓毒症的生物标记物进行总结.     

脓毒症患儿的持续血液净化治疗22例分析

目的采用持续血液净化(Continuous Blood Purification,CBP)救治儿童严重脓毒症合并脏器功能障碍,观察其临床疗效。方法对2003年8月—2005年8月,我院收治的22例儿童严重脓毒血症进行持续静脉静脉血液透析滤过(Continuous Vein-Vein Hemodialysis Filtration,CVVHDF),观察心率、血压、血管活性药物使用、自主呼吸频率、氧合指数的变化以及预后。结果22例均顺利置管并完成CBP,CBP持续时间为(64．4±34．5)h。CBP前均存在心动过速,CBP 4h下降(45±13)次/ min;CBP后,未休克的7例血压平稳;10例早期休克患儿CBP后血压维持正常,血管活性药物1～5h下调,2～8h撤除;5例难治性休克患儿CBP 4h后血压明显上升,升高幅度为(25．2±10．7)mm Hg (1mm Hg=0．133 kPa),8h恢复到该年龄正常水平,血管活性药物在CBP 2～8h下凋,4～16h停用,较早期休克患儿略延长。呼吸频率增加的患儿CBP 4h后自主频率减慢(7±4)次/min;合并呼吸衰竭患儿CBP前氧合指数(PO_2/FiO_2)为(177．7±53．1)mm Hg,CBP后4h上升至(341．0±60．2) mm Hg,(5．3±2．1)h全部达到正常;吸入氧浓度FiO_2 2～4h降至50%以内。危重评分入院时62．2±7．4,24h升高至危重评分86．6±9．0,提高24．5±10．8;CBP治疗后存活16例,存活率72．7%,治疗有效率90．9%。置换液采用改良Ports方案可导致血钙、血糖和血渗透压的升高。CBP在脓毒症患儿应用可能引起转流初期的血压轻度下降和转流过程中的出血现象。结论持续血液净化有改善严重脓毒血症儿童重要脏器的作用。     

Growth hormone and insulin-like growth factor 1 levels and their relation to survival in children with bacterial sepsis and septic shock

OBJECTIVES: Despite improved supportive care, the mortality of sepsis and septic shock is still high. Multiple changes in the neuroendocrine systems, at least in part, are responsible for the high morbidity and mortality. A reduced circulating level of insulin-like growth factor and an elevated level of growth hormone are the reported characteristic findings early in the course of sepsis and septic shock in adults. The aim of this study was to evaluate the changes of growth hormone/insulin-like growth factor 1 axis in sepsis and septic shock and investigate the relationship between these hormones and survival. METHODS: Fifty-one children with sepsis (S), 21 children with septic shock (SS) and 30 healthy, age- and sex-matched children (C) were enrolled in this study. Growth hormone, insulin-like growth factor 1 and cortisol levels of the sepsis and septic shock groups were obtained before administration of any inotropic agent. RESULTS: Growth hormone levels were 32.3 +/- 1.5 microIU/mL (range 4-56), 15.9 +/- 0.6 microIU/mL (range 11-28) and 55.7 +/- 2.7 microIU/mL (range 20-70) in S, C and SS groups, respectively. The difference between the growth hormone levels of the S and C groups, S and SS groups, and C and SS groups were significant (P < 0.001). Non-survivors (54.7 +/- 1.6 microIU/mL) had significantly higher growth hormone levels than survivors (29.4 +/- 1.5 microIU/mL) (P < 0.001). Insulin-like growth factor 1 levels were 38.1 +/- 2.1 ng/mL (range 19-100), 122.9 +/- 9.6 ng/mL (range 48-250) and 22.2 +/- 1.9 ng/mL (range 10-46) in the S, C and SS groups, respectively, and the difference between the insulin-like growth factor 1 levels of the S and C, S and SS, and C and SS groups were significant (P < 0.001). Non-survivors (8.8 +/- 1.1 micro g/dL) had significantly lower cortisol levels than survivors (40.9 +/- 2.1 microg/dL) (P < 0.001). We detected a significant difference between the levels of cortisol in non-survivors (19.7 +/- 1.8 microg/dL) and survivors (33.9 +/- 0.9 microg/dL) (P < 0.01). CONCLUSIONS: There were elevated levels of growth hormone with decreased levels of insulin-like growth factor 1 in children during sepsis and septic shock compared to healthy subjects. In addition, there were even higher levels of growth hormone and lower levels of insulin-like growth factor 1 in non-survivors than in survivors. We think that both growth hormone and insulin-like growth factor 1 may have potential prognostic value to serve as a marker in bacterial sepsis and septic shock in children. As there is insufficient data in the paediatric age group, more studies including large numbers of patients and additionally evaluating cytokines and insulin-like growth factor binding proteins are needed.     

International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.

OBJECTIVE: Although general definitions of the sepsis continuum have been published for adults, no such work has been done for the pediatric population. Physiologic and laboratory variables used to define the systemic inflammatory response syndrome (SIRS) and organ dysfunction require modification for the developmental stages of children. An international panel of 20 experts in sepsis and clinical research from five countries (Canada, France, Netherlands, United Kingdom, and United States) was convened to modify the published adult consensus definitions of infection, sepsis, severe sepsis, septic shock, and organ dysfunction for children. DESIGN: Consensus conference. METHODS: This document describes the issues surrounding consensus on four major questions addressed at the meeting: a) How should the pediatric age groups affected by sepsis be delineated? b) What are the specific definitions of pediatric SIRS, infection, sepsis, severe sepsis, and septic shock? c) What are the specific definitions of pediatric organ failure and the validity of pediatric organ failure scores? d) What are the appropriate study populations and study end points required to successfully conduct clinical trials in pediatric sepsis? Five subgroups first met separately and then together to evaluate the following areas: signs and symptoms of sepsis, cell markers, cytokines, microbiological data, and coagulation variables. All conference participants approved the final draft of the proceedings of the meeting. RESULTS: Conference attendees modified the current criteria used to define SIRS and sepsis in adults to incorporate pediatric physiologic variables appropriate for the following subcategories of children: newborn, neonate, infant, child, and adolescent. In addition, the SIRS definition was modified so that either criteria for fever or white blood count had to be met. We also defined various organ dysfunction categories, severe sepsis, and septic shock specifically for children. Although no firm conclusion was made regarding a single appropriate study end point, a novel nonmortality end point, organ failure-free days, was considered optimal for pediatric clinical trials given the relatively low incidence of mortality in pediatric sepsis compared with adult populations. CONCLUSION: We modified the adult SIRS criteria for children. In addition, we revised definitions of severe sepsis and septic shock for the pediatric population. Our goal is for these first-generation pediatric definitions and criteria to facilitate the performance of successful clinical studies in children with sepsis.     

脓毒症并多器官功能障碍综合征的血脂分析与预后关系的探讨

目的探讨血脂在脓毒症并多器官功能障碍综合征(multipleorgandysfunctionsyn-drom,MODS)患儿血中的变化及与预后的关系。方法选择符合诊断标准的34例脓毒症并MODS的患儿(其中最后存活22例,死亡12例)作为脓毒症组,检测确定诊断后第2天晨起空腹血的血脂水平,并选择同一时期同一年龄组健康体检者15例,测血脂水平做为对照,进行前瞻性研究。结果存活者与死亡者的血清胆固醇(总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇)相比差异有显著性(P<0·01),死亡者有较低浓度的血胆固醇水平;脓毒症组与对照组的血清胆固醇(总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇)相比差异有显著性(P<0·01),脓毒症组有较低浓度的血胆固醇水平,而血甘油三酯无显著性差异。结论脓毒症并MODS患儿的血胆固醇(总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇)水平与预后有关,血胆固醇(总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇)越低,预后越差。     

儿童脓毒症发生毛细血管渗漏综合征的临床危险因素分析

目的：探讨脓毒症患儿出现毛细血管渗漏综合征(CLS)时的临床特点及相关危险因素。方法：回顾分析384例脓毒症患儿的临床资料。其中一般脓毒症304例,严重脓毒症54例,脓毒性休克26例。根据是否发生CLS将病例分为非CLS组（356例）和CLS组（28例）,将两组患儿的性别、年龄、营养不良、贫血、凝血功能障碍、白细胞计数、CRP、PCT、TNF、IL-1、IL-6、血糖、乳酸、PRISM Ⅲ评分、PICS评分、严重脓毒症及休克和器官功能衰竭≥3个等因素进行单因素分析,再将有统计学意义的指标作为自变量,进行多因素logistic 回归分析。结果：脓毒性休克、严重脓毒症和一般脓毒症组患儿CLS发生率分别为42.3%、20.1%及1.3%,差异有统计学意义（P＜0.01）。贫血、凝血功能障碍、CRP、PCT＞2 ng/mL、TNF、IL-1、IL-6、血糖、乳酸、PRISMⅢ评分、PICS评分、严重脓毒症及休克和MODS≥3个在非CLS组和CLS组间比较差异均有统计学意义（P<0.05）;严重脓毒症及休克和PRISMⅢ评分为脓毒症患儿发生CLS的独立危险因素。结论：脓毒症患儿病情越严重,PRISMⅢ评分越高,发生CLS的比例越高。故对于严重脓毒症和PRISMⅢ评分越高的患儿,早期监测感染标志物及血糖等相关结果,可能有助于早期识别CLS及积极干预,降低儿童脓毒症合并CLS的病死率。     

脓毒性休克患儿死亡危险因素分析

目的：探讨脓毒性休克患儿的死亡危险因素,以指导脓毒性休克患儿的治疗,降低死亡率。方法：对53例脓毒性休克患儿10项可能的危险因素先进行单因素分析,然后对单因素分析有显著意义的因素做多因素logistic回归分析。结果：单因素分析和logistic回归分析显示动脉血pH值<7.0、低血压、器官功能障碍数目≥3个、小儿危重病例评分<70分、未在休克后6 h内完成容量复苏、未在休克后1 h内使用有效抗生素、未合理应用血管活性药物为脓毒性休克患儿死亡的危险因素。结论：动脉血pH值<7.0、血压下降、器官功能障碍数目≥3个、小儿危重病例评分<70分的脓毒性休克患儿预后差、死亡率高。若在休克后1 h内能使用有效抗生素、6 h内能完成容量复苏、并能合理应用血管活性药物,则可提高脓毒性休克患儿的治愈率,降低死亡率。［中国当代儿科杂志,2009,11（4）：280-282］     

Thyroid function in children with sepsis and septic shock

AIM: A prospective study was conducted to determine thyroid hormone levels and their relationship to survival in children with septic shock and sepsis. METHODS: We estimated thyroid hormone levels (T3, T4, TSH, fT3 and fT4) in children with septic shock and compared with those in children with sepsis. RESULTS: Twenty-four children (13 boys) with septic shock and 25 children (14 boys) with sepsis were enrolled. The median T3, T4, fT3, fT4 and TSH (95% confidence interval) were 40 (40-40.23) ng/dL, 4.45 (1.9-6.03) microg/dL, 1.85 (1.2-2.37) pg/mL, 0.77 (0.57-0.95) ng/dL, 0.51 (0.26-1.15) microIU/mL, respectively in children with septic shock group compared with 130 (98.28-163.48) ng/dL, 9.3 (7.66-10.63) microg/dL, 3.2 (3-4.27) pg/mL, 1.3 (1.1-1.4) ng/dL, 2.85 (1.07-3.61) microIU/mL, respectively, in children with sepsis. Children with septic shock who died (n = 12) had higher TSH levels compared to those who survived (p = 0.04). There was no difference in hormone levels between children with catecholamine responsive and catecholamine resistant septic shock. CONCLUSION: Children with septic shock had lower levels of T3, T4, fT3, fT4 and TSH compared to those with sepsis. Findings of our study suggest that derangement of thyroid functions in children is not an important factor contributing to the severity of septic shock.     

Disseminated intravascular coagulation in pediatric patients: clinical and laboratory features and prognostic factors influencing the survival

Although disseminated intravascular coagulation (DIC) has been a well-known disorder for many years, there is lack of sufficient number of clinical trials about incidence, frequency of underlying disorders, and prognosis of DIC in children. The aim of this study was to evaluate the frequency, etiologic factors, and clinical and laboratory findings of DIC and to determine the prognostic factors influencing the mortality in hospitalized pediatric patients. Medical records of 5535 children who were hospitalized were investigated. Sixty-two patients who were diagnosed as acute DIC were enrolled. The frequency of DIC was 1.12%. The underlying etiologic factors were infection in 59 patients (95.2%) and major trauma in 3 patients (4.8%). The frequency of bleeding and thrombosis was 48.8 and 4.8%. Respiratory, cardiovascular, hepatic, renal, neurologic, and gastrointestinal dysfunction was present in 71, 67.7, 35.5, 16.1, 16.1 and 11.3% of patients, respectively. Respiratory and cardiovascular dysfunctions were significantly associated with mortality. Multiorgan dysfunction syndrome (MODS) was present in 85.5% of the patients, and 54.8% of the patients had developed acute respiratory distress syndrome (ARDS). Mortality rate was significantly high in patients with MODS and ARDS. In multivariete logistic regression analysis, only ARDS and cardiovascular dysfunction had predictive and prognostic value on mortality. None of the diagnostic laboratory tests had predictive or prognostic value and the degree of abnormality of these tests did not show any correlation with mortality. In conclusion, DIC is not a rare disorder in hospitalized children, especially in patients with sepsis, and MODS, ARDS, and respiratory and cardiovascular system dysfunctions are poor prognostic factors.     

促肾上腺皮质激素刺激对脓毒症及脓毒性休克患儿肾上腺功能评估的意义

目的 探讨小剂量(1μg/1.73 m2)促肾上腺皮质激素(ACTH)刺激实验评估儿童脓毒症和脓毒性休克肾上腺功能状态的价值.方法 患儿入院24h内完成基础皮质醇(T0)测定,静脉注射1μg/1.73m2 ACTH,30 min后测定血液皮质醇(T1),根据T0和皮质醇增值(△max=T1-T0)判断肾上腺功能,以△max≤90μg/L为肾上腺功能障碍(AI)指标.结果 62例中,脓毒症53例,脓毒性休克9例,病死率为27.4%(17/62).肾上腺功能障碍(adrenal insufficiency,AI)发生率40.3%(25/62),其中脓毒症和脓毒性休克患儿AI发生率分别是39.6%和44.4%,差异无显著统计学意义(P>0.05).两组脓毒症和脓毒性休克平均T0和T1分别是(318.6±230.4)μg/L、(452.3±230.7)μg/L和(454.7±212.7)μg/L、(579.3±231.9)μg/L,差异无统计学意义(P>0.05).存活组和死亡组患儿T0、T1分别是(320.5±223.9)μg/L、(462.3±212.0)μg/L和(384.3±258.3)μg/L、(500.7±470.6)μg/L,两组AI发生率分别是37.8%和47.1%,差异无统计学意义(P>0.05).T0和T1水平与儿童危重病例评分(PCIS)有关(P<0.05),AI发生率与PCIS、PRISMⅢ和器官功能障碍数目无关(P>0.05).结论 儿童脓毒症和脓毒性休克患儿AI发生率较高.小剂量ACTH刺激实验可以判断严重感染患者肾上腺功能,可为激素治疗提供依据.     

危重病患儿急性颅内高压及脑水肿的病因和病死危险因素分析

目的　调查儿科重症监护病区 (PICU)危重病患儿发生急性颅内高压及脑水肿的原因、流行病学特点和病死危险因素。方法　总结 1999年 1月 - 2 0 0 3年 12月 ,我院PICU危重病患者中 ,急性颅内高压及脑水肿患儿的病因、预后与多器官功能不全综合征 (MODS)的关系。利用队列研究对患者病死危险因素进行分析。结果　 14 4 6例危重病患儿中 ,2 16例发生急性颅内高压及脑水肿 ,病死率2 9 2 %。 5年间病死率无明显变化 (χ2 =0 371,P =0 985 )。神经系统与非神经系统原发疾病病死率差异无统计学意义 (χ2 =0 5 4 6 ,P =0 4 6 0 )。神经系统感染、意外伤害和败血症是常见病因 ,分别占2 7 8%、2 2 4 %和 10 2 %。对 12个死亡因素进行统计学分析 ,显示合并器官衰竭数目、年龄小、入科当日危重评分值、有基础疾病、呼吸衰竭和瞳孔大小改变与病死率显著相关 (P <0 0 5或P <0 0 0 1)。结论　 1999年以来 ,颅内高压及脑水肿患儿的病死率依然很高。神经系统感染、意外伤害和败血症是主要发病危险因素 ;患病年龄小于 1岁、低危重评分及合并MODS是病死主要危险因素。     

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??Abstract: Objective To investigate the related factors?? clinical features and prognosis of septic shock in children with acute leukemia. Methods Analyse the clinical features??therapeutic measures??effect and death risk factors of eighteen children with acute leukemia and septic shock in our hospital from Jan.1??2005 to Jun.1??2012. Result Male children 15 cases ??83.3%???? with a mean onset age of 9.8 years?? the average strong chemotherapy treatment of 6.5 times. All children’s neutrophile granulocyte count was lower than 0.5 × 109 / L??hypoalbuminemia occurred in 13 cases ??13/15??86.7%???? cardiac dysfunction in 12 cases ??66.7%???? pneumonia in 13 cases ??72.2%???? MODS in 7 cases ??38.9%??. Bacterial culture was gram negative ??G -?? bacillus in 9 cases??including pseudomonas aeruginosa??3 cases????gram positive??G +?? bacteria in 2 cases?? both were hemolytic staphylococcus. Among the 18 cases?? 1 gave up treatment?? 6 cases died?? 11 cases were cured?? and the mortality rate was 35.3%. Single factor analysis results showed that the use of sensitive antibiotics within 24 hours during fever in the shock-correction group and the death group had statistical significances?? as well as the occurrence of MODS in the process of shock rescue ??P??0.05??.Shock merger pneumonia?? cardiac dysfunction?? and refractory-relapsed patients had no statistical significance. Conclusion The older boys?? agranulocytosis?? multiple chemotherapy and hypoalbuminemia are high risk factors of septic shock. Gram negative bacilli is more in bacterial culture?? especially pseudomonas aeruginosa.Staphylococcus heamolyticus can’t be ignored. Patients with cardiac dysfunction are common?? but CK - MB doesn't increase or increase obviously?? Not using sensitive antibiotics within 24 hours since fever occurs and MODS are the high-risk factors causing death. Using sensitive antibiotics as soon as possible and supportting the organ function actively are important measures to reduce the death of children with septic shock.     

Ferritin levels in children with severe sepsis and septic shock

AIM: To evaluate serum ferritin level in children with severe sepsis and septic shock and its association with mortality. METHOD: A cohort study of 36 children aged 1 month-16 years with severe sepsis or septic shock requiring intensive care was conducted. Serum ferritin levels were measured at the time of diagnosis of sepsis and a ferritin index (FI=observed serum ferritin divided by the upper limit of normal ferritin for age and gender) was calculated. RESULTS: The median age (range) of the children was 6 (2-100) months. Ferritin was <200 ng/mL in 13 children, 200-500 ng/mL in 11 children and >500 ng/mL in 12 children. The mortality associated with these groups was 23%, 9% and 58%, respectively. A ferritin>500 ng/mL was associated with a 3.2 (1.3-7.9) relative risk of death (p=0.01). FI of 1.7 was the best cutoff value for identifying those who died. In a logistic regression analysis, ferritin level and PRISM were independently associated with mortality. CONCLUSIONS: Ferritin is raised in children with septic shock and high ferritin level is associated with poorer outcome.     

血乳酸在脓毒症患儿病情及预后评价中的意义

目的 探讨脓毒症患儿血乳酸水平对病情严重程度和预后的评价作用。方法 收集脓毒症患儿484例,其中普通脓毒症组310例、严重脓毒症组105例、脓毒症休克组69例,治疗前测动脉血乳酸值,对乳酸>2 mmol/L的脓毒症休克患儿,收集其早期液体复苏后血乳酸复查值。结果 随脓毒症严重程度增加,血乳酸值逐渐增加。ROC曲线分析发现,区别脓毒症休克和非脓毒症休克的血乳酸值为2.25 mmol/L时,其诊断灵敏度为82.6%,特异性为79.8%。乳酸≤1 mmol/L、乳酸~2 mmol/L、乳酸~4 mmol/L和乳酸>4 mmol/L患儿的病死率分别为8.5%、9.4%、27.2%、67.6%,乳酸>4 mmol/L的死亡风险为乳酸≤1 mmol/L的22.4倍。治疗前血乳酸>2 mmol/L的脓毒症休克患儿复苏后血乳酸水平≤2 mmol/L和>2 mmol/L的病死率分别为33.3%、69.2%。结论 血乳酸可作为脓毒症患儿病情严重程度及预后的评价指标,血乳酸值2.25 mmol/L对脓毒症休克具有较高的诊断价值;早期复苏使血乳酸水平恢复至正常可改善脓毒症休克患儿的预后。