48例儿童感染性休克死亡相关因素临床分析

目的了解儿童感染性休克病死率及相关危险因素。方法回顾分析我院48例儿童感染性休克病死率与MODS发病率、休克持续时间、血清白蛋白浓度、CRP、肿瘤、粒细胞数、碱剩余等的关系。结果感染性休克病死率31．25％，MODS患病率43．75％；伴有MODS的感染性休克病死率为71．4％(15／21)，明显高于不伴MODS者；死亡组感染性休克持续时间明显长于治愈组；休克治疗后治愈组血清白蛋白上升，而死亡组则继续下降，两组血清白蛋白存在显著差异；肿瘤组与非肿瘤组MODS发生率无明显差异，肿瘤组病死率明显高于非肿瘤组；感染性休克预后与粒细胞数、CRP、pH值等无关。结论儿童感染性休克病死率较高，与MODS、休克持续时间、血清白蛋白浓度、肿瘤等因素相关。     

48例儿童感染性休克死亡相关因素临床分析

目的了解儿童感染性休克病死率及相关危险因素。方法回顾分析我院48例儿童感染性休克病死率与MODS发病率、休克持续时间、血清白蛋白浓度、CRP、肿瘤、粒细胞数、碱剩余等的关系。结果感染性休克病死率31.25%,MODS患病率43.75%;伴有MODS的感染性休克病死率为71.4%(1521),明显高于不伴MODS者;死亡组感染性休克持续时间明显长于治愈组;休克治疗后治愈组血清白蛋白上升,而死亡组则继续下降,两组血清白蛋白存在显著差异;肿瘤组与非肿瘤组MODS发生率无明显差异,肿瘤组病死率明显高于非肿瘤组;感染性休克预后与粒细胞数、CRP、pH值等无关。结论儿童感染性休克病死率较高,与MODS、休克持续时间、血清白蛋白浓度、肿瘤等因素相关。     

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］     

新生儿感染性休克17例死亡病例分析

新生儿感染性休克（脓毒症休克）为重症病例,死亡率高,须尽早判断、及时诊治,国外己制订出新生儿全身炎症反应综合征（SIRS）的诊断标准,用以从病理生理学角度去早期发现脓毒症（sepsis）及多脏器功能衰竭（MSOF）病例,本研究拟通过对新生儿感染性休克死亡的17例死亡病例进行分析,以探讨感染性休克的严重性及与SIRS、MSOF的关系.     

小儿感染性休克进一步重视的问题

1981～1987年6月在我院住院患儿中有69例发生感染性休克,其原发病为:流脑20例(29%),中毒性菌痢17例(24.7%),败血症12例(17.4%),出血性小肠炎6例(8.7%),肺炎5例(7.2%),肠炎4例(5.8%),其他5例(7.3%,包括化脓性脑膜炎2例,病毒性脑膜炎1例,急性胰腺炎1例及鼠伤寒沙门氏菌感染1例)。现就近年来我们对感染性休克临床及实验室观察到几个问题提出讨论,以进一步提高抢救率。     

感染性休克的循环评估

正确评估感染性休克患儿的循环状态是成功治疗的基础。临床工作中评估休克患儿循环状态的方法包括临床表现、血流动力学监测及反映组织氧合的检测指标。进行循环评估时应注意各项评估指标相结合,同时随病情进展进行动态监测。     

感染性休克的诊断治疗进展

感染性休克（septicshock，SS）也称脓毒性休克，是儿科常见危重症，其诊治一直是大家关注的热点。20世纪70年代，我国学者在救治暴发型流行性脑脊髓膜炎和中毒性痢疾患儿的工作中积累了丰富的经验，成功挽救了许多SS患儿的生命。但严重脓毒症在世界范围内依然是造成儿童死亡的重要原因。     

感染性休克诊疗建议

2006年小儿危重病协会国际联盟发起全球拯救脓毒血症小儿倡议。出现炎症反应三联征及神志改变时应疑有感染性休克,可依据临床表现及治疗效果分为冷休克、暖休克,液体抵抗、多巴胺抵抗、儿茶酚胺抵抗及难治性休克。救治目标:第1 h应维持正常的通气、呼吸及循环功能,第一小时后应维持正常的灌注压,上腔静脉血氧饱和度>70%,心脏指数(CI)>3.3 L/(min.m2)及<6 L/(min.m2)。合理的监护、液体复苏及序贯化药物应用是最重要的三大救治措施。     

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??Objective??To study clinical characteristics and risk factors for mortality of septic shock patients with hematological malignancies in pediatric intensive care unit??PICU??. Methods??A retrospective analysis of records of pediatric patients with hematological malignancy and septic shock was performed. In our study??43 cases admitted to PICU in Sun Yat-sen Memorial Hospital between March 2012 and September 2015 were included. Results??Among the 43 cases??16 died??while the other 27 survived. The percentage of mortality was 37.2%. Pulmonary infection ??74.4%?? and gastrointestinal tract infection??39.5%?? were the common causes of septic shock in these patients. Etiological examination revealed 43 kinds of pathogenic bacteria in 26 cases. The percentage of gram-positive bacteria??gram-negative bacteria and fungus was 11.6%??72.1% and 16.3%??respectively. Escherichia coli was found to be the main pathogen??6/43??14.0%??. Between the survival group and the mortality group??there were significant differences in the parameters of age??chemotherapy courses??time from infection to shock??time from neutropenia to shock??multiple organs dysfunction??pulmonary infection??hypocalcemia??oxygenation index and serum lactic acid concentration after 6 hours of fluid resuscitation??requirement of dopamine and mechanical ventilation ??P??0.05??. By logistic regression analysis??mortality was associated with the variables of serum lactic acid concentration after 6 hours of fluid resuscitation and requirement of mechanical ventilation. Conclusion??The risk factors for mortality of septic shock in pediatric patients with hematological malignancies are hyperlactacidemia after 6 hours of fluid resuscitation??hypocalcemia and requirement of mechanical ventilation.     

血浆vW因子抗原检测在儿童感染性休克中的意义

目的　 探讨血浆vonWillebrandFactorAntigen(vWf :Ag)在儿童感染性休克中的临床意义。 方法 　用ELISA方法检测 9例休克死亡组、11例休克存活组及 10例健康对照组患儿血浆vWf:Ag(vW因子抗原 ) ,同时用酶比色法检测这 2 0例感染性休克患儿的动脉血乳酸。 结果 　血浆平均vWf :Ag休克死亡组 (710 9± 3 9 4) %明显高于休克存活组 (5 94 5± 5 8 6) % (P<0 0 0 0 1)和健康对照组 (93 8± 16 1) % (P <0 0 0 0 1)。 2 0例休克患儿血浆平均vWf:Ag(64 6 9± 77 3 9) %与平均动脉血乳酸浓度 (3 96± 1 0 0 5 )mmol/L呈正相关 (r =0 886) ,与器官衰竭数目亦成正相关 (rs=0 92 9)。 结论 　vWf:Ag的测定可以作为血管内皮损伤标志物和感染性休克发展为多脏器功能衰竭的一个预警指标     

不同液体疗法在治疗小儿感染性休克中的作用

目的比较两种液体疗法在治疗小儿感染性休克中的作用。方法感染性休克患儿48例,用传统扩容法治疗27例,液体复苏法治疗21例,其他抗感染及血管活性药物使用原则相同。比较两种方法治疗患儿的循环稳定时间、肺水肿发生率、PICU住院时间及死亡率。结果液体复苏法组患儿达到循环稳定时间[(121.63±75.59)min]较传统扩容组[(216.10±168.13)min]明显缩短(P0.05);液体复苏法组患儿肺水肿发生率(9.5%)与传统扩容组(14.8%)相比差异无统计学意义(P0.05);液体复苏法组患儿PICU住院时间[(3.944±2.711)d]较传统扩容组[(6.188±3.250)d]明显缩短(P0.05);液体复苏法组患儿死亡率(14.3%)明显低于传统扩容组(40.7%)(P0.05)。结论液体复苏法能使患儿循环较快获得稳定,缩短PICU住院时间,并提高患儿生存率,而不会引起更多并发症,值得临床推广。     

血清CRP在小儿感染性休克中临床意义的探讨

目的　探讨血清C反应蛋白 (CRP)在感染性休克患儿中诊断及疗效观察中的临床意义。方法　选择符合诊断标准的 5 1例感染性休克患儿为实验组 ,其中好转存活患儿 2 5例 ,死亡患儿 2 6例 ;2 5例一般感染患儿为对照组。测定各组患儿入院及经治疗 3d、7d的血清CRP水平 ,进行回顾性研究。结果　入院时CRP值 ,死亡组、存活组与一般感染组相比有显著性差异 (P <0 0 1 ) ;存活组入院治疗 3d与入院时比较无显著性差异 ,而治疗 7d较前均明显降低 ,有显著性差异 (P <0 0 1 ) ;死亡组治疗 3dCRP水平与入院时相比有显著性差异 (P <0 0 1 )。结论　血清CRP值的高低与感染性休克危重症严重程度有关 ,CRP越高 ,病情越重 ,预后越差。血清CRP水平可作为感染性休克病情发展及疗效评价的指标。     

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??Abstract Objective??To research the advantages of plasma colloid osmotic pressure ??COP??monitoring in fluid resuscitation of pediatric patients in septic shock. Methods??A total of 47 pediatric patients in septic shock were divided randomly into 2 groups?? all cases were dynamically monitored COP??and under went fluid resuscitation. In Group A ??22 cases???? fluid infused depending on clinical experience??and COP indexes were not considered. Only normal sodium was used in quick transfusion period. Crystal vs colloid fluid was 2??3 ?? 1 during continuing and sustaining transfusion period.In Group B ??25 cases???? if COP was lower than normal??more colloid fluid was used in quick transfusion period and Crystal vs colloid fluid was 1 ?? 1 during continuing and sustaining transfusion period??otherwise ??treatments were the same as in group A. Average artery pressure??MAP???? urine volume per hour?? central venous pressure ??cvp????fluid resuscitation volume?? usage amount of vasoactive drug??and pediatric critical illness scores ??PCIS scores?? of two groups were recorded and statistically analyzed. Results??At first??COP??PCIS scores??MAP and CVP were similar between group A and B?? COP was obviously lower than normal. Colloid fluid volume and COP of group B in every period were more than group A. Total fluid volume of group B during 6 and 24 hours were less than group A?? at 1 and 6 hour?? PCIS scores?? urine volume per hour?? MAP and CVP of group B were more than group A?? usage amount of vasoactive drug was less than group A. After 24 hours?? PCIS scores?? urine volume per hours?? MAP??CVP were similar between group A and B?? but in group B usage amount of vasoactive drug was less than that in group A. Conclusion??Monitoring COP during fluid resuscitation of pediatric patients in septic shock?? and adjusting ctystal colloid proportion depending on it ?? was helpful to increase curative effect.     

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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.     

感染性休克时内环境紊乱与治疗策略

感染性休克可引起机体代谢、凝血、内分泌等系统功能障碍,从而导致一系列内环境紊乱。正确认识这些内环境紊乱及对机体的不利影响,采取恰当的治疗策略是非常重要的。关于感染性休克时代谢性酸中毒的纠正、凝血障碍及应激性高血糖的治疗目前尚有争议,应遵循根据循证医学证据制订的指南推荐意见。     

Noradrenaline use for septic shock in children: doses, routes of administration and complications

Aim: To report our 10 year experience with noradrenaline use in children with septic shock focusing on doses, routes of administration and complications. Methods: Retrospective single‐centre review of children with septic shock who received noradrenaline between 2000 and 2010. Results: We identified 144 children with septic shock treated with noradrenaline, in 22% as the first‐line drug. The median volume resuscitation before vasoactive agent administration was 50 mL/kg interquartile range [IQR: 30–70]. Mean doses of noradrenaline ranged from 0.5 ± 0.4 μg/kg per min (starting dose) to 2.5 ± 2.2 μg/kg per min (maximum dose). Noradrenaline was administered via peripheral venous access or intra‐osseous route in 19% of cases for a median duration of 3 h [IQR: 2–4] without any adverse effects. The use of noradrenaline increased over the study period. Mortality rate was 45% with a significant decrease over the study period. Adverse effects included arrhythmia in two children and hypertension in eight children. None of these arrhythmias required treatment and hypertension resolved with the noradrenaline dose reduction. Conclusion: Higher doses of noradrenaline than those suggested in the literature may be necessary to reverse hypotension and hypoperfusion. The use of noradrenaline through peripheral venous access or intra‐osseous route was safe, without any adverse effects.     

瘦素在严重感染及脓毒性休克中作用的研究进展

瘦素(leptin,LP)是一种主要由脂肪细胞分泌的细胞因子,受肥胖基因调节,通过中枢和外周调节摄食和体质量的平衡.同时,LP参与免疫应答、抗炎和创伤修复等病理生理过程.新近发现LP可通过抑制中性粒细胞和单核细胞活化和坏死,对危重病患者脏器功能可能有保护作用.严重感染时,LP的改变对判断脓毒症及脓毒性休克预后有一定的参考价值.本文综述在严重感染及脓毒性休克时LP的表达及与主要细胞因子的关系.