高容量血液滤过对脓毒性休克患儿血流动力学及血管内皮通透性的影响

目的 比较分析高容量血液滤过对脓毒性休克患儿血流动力学、血管活性因子及血管内皮通透性的影响。方法 2013 年1 月至2014 年9 月确诊为脓毒性休克的36 例患儿被随机分为对照组和观察组,每组18 例。对照组采用常规容量血液滤过进行治疗,观察组采用高容量血液滤过进行治疗。比较两组患儿治疗前后的血流动力学指标及血管活性因子[6-酮-前列腺素F1α(6-keto-PGF1α)、血栓素B2(TXB2)、可溶性E-选择素(sE-selectin)和血管内皮舒张因子(EDRF)]的变化情况,分析超滤液对血管内皮细胞通透性的影响。结果 与对照组相比,治疗后观察组平均动脉压和血氧饱和度显著升高,心率显著下降(PPP结论 与常规容量血液滤过治疗相比,高容量血液滤过治疗能更有效改善脓毒性休克患儿的血流动力学及血管活性因子水平,降低血管内皮细胞的通透性。     

儿童脓毒性休克诊治专家共识--我们需要关注哪些变化

《儿童脓毒性休克（感染性休克）诊治专家共识（2015版）》已发表,是在国际指南的引领下,并结合国内外大量研究文献,在2006年制定的《儿科感染性休克（脓毒性休克）诊断治疗推荐方案》基础上,主要就儿童脓毒性休克定义、诊断和早期集束化治疗方案进行了部分修订。《儿童脓毒性休克（感染性休克）诊治专家共识（2015版）》的制定旨在指导临床一线医师对儿童脓毒性休克早期识别和早期积极干预,并进一步降低病死率和改善预后。     

循环衰竭患儿氧运输和代谢监测的意义

循环衰竭时组织氧供不足及氧摄取利用障碍是其基本病理生理改变,是各种休克共同的病理生理基础.氧代谢监测的发展不仅改变了对休克的评估方式,对休克治疗也产生深远影响.全身及组织氧代谢状态监测和调控,成为未来循环衰竭诊治的方向.     

Recent advances in sepsis and septic shock

Sepsis remains a common problem in all age groups. Recently surviving sepsis campaign has taken up a worldwide initiative by publishing international guidelines 2008 with a hope to disseminate information regarding management of sepsis for all age groups. This article presents a review of recent advances as they apply to pediatric age group supported by the available evidence with reference to standard definitions of pediatric sepsis and septic shock and management in the emergency room and pediatric intensive care unit.     

Vasopressin infusion in children with catecholamine-resistant septic shock

Aim : To describe use of vasopressin infusion for catecholamine-refractory septic shock in children. Methods : We report successful use of vasopressin infusion in three children with septic shock, in whom hypotension and poor perfusion persisted despite use of multiple infusions of vasopressors and inotropes. Results : All three had a rapid improvement in hypotension and perfusion after starting vasopressin infusion, allowing tapering of other infusions. Two children recovered completely.

Conclusions

: Vasopressin appears to be useful in treatment of catecholamine-refractory septic shock in children.     

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.     

脓毒性休克患儿外周血淋巴细胞亚群的动态变化及临床意义

目的：探讨脓毒性休克(septic shock,SS)患儿外周血淋巴细胞亚群(总淋巴细胞、CD3＋T、CD4＋T、CD8＋T、CD19＋B、CD56＋NK)计数的变化特点及对预后的影响。方法检测 SS 重度组25例、SS轻度组24例入院时的外周血淋巴细胞亚群,并与同期健康体检小儿(正常对照组)25例进行比较分析。SS 重度组、轻度组于入院后第3、8天动态监测以上指标,同时记录病情变化和预后转归,并根据 SS 重度组转归分为死亡组与存活组,比较上述指标。结果入院时 SS 重度组、轻度组的淋巴细胞各亚群计数与正常对照组比较均有明显降低,三组相比差异具有显著性(P ＜0.05)。入院第3天,SS 轻度组的 CD4＋T、CD3＋T、总淋巴细胞计数较入院时有显著升高(P ＜0.05);SS 重度组除了 NK 细胞外,其余淋巴细胞亚群均较入院时显著降低(P ＜0.05)。入院第8天,SS 轻度组的 CD4＋T 计数与正常对照组比较已无显著差异(P ＞0.05);SS 重度组的 CD4＋T、CD3＋T、总淋巴细胞计数较入院时有显著升高,但与正常对照组比较差异仍有统计学意义(P ＜0.05),其余淋巴细胞亚群计数有所上升。SS 患儿重度组5例死亡(死亡组)均发生在入院后2～5 d,与其余生存的20例(存活组)相比,两组入院时的淋巴细胞各亚群计数比较无显著差异,死亡组入院第3天的淋巴细胞各亚群计数值明显降低,与存活组同期存在显著差异(P ＜0.05)。结论SS 患儿外周血淋巴细胞各亚群计数值越低,病情越严重,持续低水平提示死亡风险大;经过治疗,病情有效控制者首先表现为 CD4＋T、CD3＋T、总淋巴细胞计数上升,尤其是 CD4＋T。因此,动态监测 SS 患儿的淋巴细胞亚群对判断病情的严重程度、疗效、预后具有较高临床价值。     

Myocardial cell injury is common in children with septic shock

Objective: To determine the prevalence of myocardial cell injury in children with septic shock by estimating the levels of biochemical markers of myocardial injury, troponin I (TnI) and creatine kinase MB (CK-MB).
Patients: Children aged 3 months to 16 years were admitted to paediatric intensive care unit (PICU) with septic shock. Children with sepsis without shock and children with hypovolaemic shock were enrolled as controls.
Measurements and Main Results: Serum TnI and CK-MB levels were measured at admission and serially at 24 h, 48 h and 96 h in children with septic shock, while baseline measurement of the same markers was taken from the controls. In total, 88% (15/18) of children with septic shock had elevated TnI levels compared with 25% (5/20) with sepsis and 6.7% (1/15) with hypovolaemic shock (p < 0.001). Serial TnI levels at admission, 24 h, 48 h and 96 h were higher in the nonsurvivors. There was a positive correlation between the baseline TnI levels and the predicted mortality using the paediatric index of mortality (PIM2) scores at admission (r = 0.51, p = 0.03).
Conclusion: A majority of children with septic shock have evidence of myocardial cell injury. The estimation of serum TnI levels may help in better prognostication of children with septic shock.     

小儿脓毒性休克的治疗探讨

目的探讨小儿脓毒性休克新推荐方案的治疗效果。方法收集采用传统方案治疗的脓毒性休克患儿82例(传统方案组)和采用新推荐方案治疗的脓毒性休克患儿59例(新推荐方案组),对两组的休克纠正率、病死率、急性呼吸窘迫综合征的治疗有效率进行比较。结果新推荐方案组采取早期多组生理盐水快速扩容使休克纠正率明显提高(30%vs86%,P<0.01);使用小剂量琥珀酸氢化可的松可使脓毒性休克患儿的病死率降低(50%vs32%,P<0.01);保护性肺通气策略有助于降低脓毒性休克合并急性呼吸窘迫综合征的病死率,但差异无显著性(70%vs32%,P>0.05);采用新推荐方案治疗后脓毒性休克患儿病死率明显降低(62%vs44%,P<0.01)。结论应用新推荐方案针对脓毒性休克患儿的不同时期和并发症及时恰当的治疗,可降低其病死率。     

新生儿脓毒症研究进展

新生儿脓毒症是新生儿期细菌或真菌侵入血液循环并在其中生长繁殖,产生毒素所造成的全身性感染.目前该类疾病的发病率和病死率仍占新生儿感染性疾病首位.根据新生儿自身特点该类疾病的临床表现不明显,给临床带来了一系列问题.本文就新生儿脓毒症的流行病学、病因、病理生理、临床特点及与成人脓毒性休克的异同点等方面作一综述,以加深对新生儿脓毒症的认识.     

内外源性儿茶酚胺对脓毒性休克心肌的影响

为了阐述脓毒症发展到脓毒性休克内源性儿茶酚胺升高及外源性儿茶酚胺的大量应用对脓毒性休克心功能不全发生的作用,本文从儿茶酚胺与心脏、儿茶酚胺所致心脏毒性、脓毒性休克交感-肾上腺素系统激活状态及外源性儿茶酚胺类药物的应用阐述可能对心肌的影响.     

Management of Meningococcemia

Meningococcemia causes substantial morbidity and mortality worldwide, usually in the term of fulminant disease. This paper reviews the background, pathophysiology, clinical manifestations, and treatment of this entity, along with prevention measures and public health issues to be considered. The authors present updated information on breakthroughs in the understanding of genetic predisposition to invasive disease. The status of adjunctive treatment modalities such as monoclonal antibodies and activated protein C, and progress in conjugate vaccine development and implementation are also addressed.     

脓毒性休克血流动力学监测及容量、心功能状态评估

血流动力学监测是对循环系统血液流动,心脏各腔室压力,体循环、肺循环的压力及阻力等一系列生理病理变化的指标进行监测.脓毒性休克传统血流动力学监测以中心静脉压、心脏指数、血乳酸和pH为重要参考依据.近年来发展的无创或有创监测技术包括中心静脉或混合静脉血氧饱和度、连续无创超声心输出量监测、脉搏指数连续心排血量监测等.宏观血流动力学、代谢指标和微循环参数构成新的血流动力学监测数据网络.临床需要通过对各个参数进行分析与整合,克服单一参数的局限性,才能正确评估患儿容量及循环功能状态.     

儿童与成年人感染性休克的主要异同

感染休克的患儿首次就诊并非都能在大医院PICU中住院治疗,而且在病理生理上儿童感染性休克和成人的感染性休克并不一致.因此,每个医生（包括内科、儿科）都有可能面对处于急诊状态下感染休克的患儿,正确认识理解儿童感染性休克的特点并熟悉其主要的治疗原则及措施显得尤其重要.     

亚甲蓝对小儿感染性休克血液动力学和氧代谢影响的临床观察

目的　 观察亚甲蓝在小儿感染性休克中的疗效。 方法 　 44例小儿感染性休克患儿随机分成实验组和对照组 ,对照组按休克常规治疗。实验组除按休克常规治疗外 ,早期应用亚甲蓝治疗 ,并对两组患儿进行血液动力学及氧代谢指标监测。 结果　实验组患儿总治愈率、重型休克治愈率明显高于对照组 ;血液动力学指标改善较对照组明显 ;氧代谢变化两组患儿大致相同。 结论 　亚甲蓝能改善感染性休克患儿血液动力学方面异常 ,提高感染性休克治愈率。     

脓毒性休克规范化液体复苏治疗中的特殊性

脓毒性休克规范化液体复苏具有普遍指导意义,但不同的个体表现出的病理生理特点并非一致,液体复苏要注意具体患儿所表现出的特殊性.本文就脓毒性休克规范化液体复苏治疗中应考虑的特殊性进行讨论.     

小剂量氢化可的松对脓毒性休克大鼠脑损伤的影响

目的 探讨小剂量氢化可的松(hydrocortisone,HC)对脓毒性休克大鼠脑损伤的影响.方法 选用5～6周龄清洁级雄性Wistar大鼠,按随机数字表法随机分为内毒素组[脂多糖(lipopolysaccharide,LPS)组,以等量生理盐水取代HC]、小剂量HC组(HC 5 mg/kg)及正常对照组(以等量生理盐水取代LPS及HC).每组各10只.模型建立后6h,取静脉血测血清神经元特异性烯醇化酶(neuronspecific enolase,NSE),迅速麻醉大鼠致死取脑,分离左右脑,测脑组织含水量,病理观测脑组织炎症反应评分、神经元损伤评分和血管反应评分.结果 LPS组大鼠血清NSE、脑组织含水量、炎症反应评分、神经元损伤评分、血管反应评分均较正常对照组显著升高[(10.078 ±0.526) μg/L vs.(3.719 ±0.602) μg/L,(82.328 ±0.011)％vs.(78.896 ±0.005)％,(2.750 ±0.463)分vs.(0.125±0.345)分,(2.875±0.353)分vs.(1.125 ±0.354)分,(2.875±0.463)分vs.(0.500±0.534)分,P均＜0.01];应用HC干预后,小剂量HC组大鼠血清NSE、脑组织含水量、炎症反应评分、神经元损伤评分、血管反应评分[(6.297±1.393) μg/L,(80.283±0.005)％,(0.625 ±0.744)分,(1.375±0.744)分,(1.250±0.463)分]较LPS组均明显降低(P均＜0.05).结论 使用小剂量HC进行干预,可使脑损伤生化指标、脑水肿、炎症损伤、神经元损伤、血管反应等有不同程度的改善,提示小剂量HC对脓毒性脑病可能有保护作用.