重症监护室免疫抑制和免疫健全脓毒症患儿28天内死亡因素的病例对照研究

目的评估伴免疫抑制相关基础疾病的儿童重症监护室脓毒症患儿入PICU 28 d内死亡及其危险因素。方法病例对照研究。回顾性收集复旦大学附属儿科医院（我院）因脓毒症/脓毒性休克收入PICU的患儿临床资料,分为免疫抑制组和免疫健全组,考察免疫抑制患儿入PICU 28 d内死亡的危险因素。结果2015年12月1日至2018年12月31日我院PICU出院诊断脓毒症连续病例385例,排除入科后24 h内死亡和PICU获得性脓毒症病例,251例PICU脓毒症/脓毒性休克患儿进入本文分析,免疫抑制组110例 (43.8%),免疫健全组141例。与免疫健全组比较,免疫抑制组以住院转入患儿（70%）为主,PICU维持治疗需求（血管活性药物、有创/无创机械通气）高、24 h PRISM评分高,不明确感染部位比例高,免疫抑制组接受ECMO治疗者全部死亡,持续肾脏代替治疗（CRRT）存活率为17.4%,入PICU第28 d病死率69.1%。免疫健全组和免疫抑制组28 d内存活和死亡患儿比较,除脓毒性休克、有创机械通气、CRRT、PRISM Ⅲ评分、乳酸>2 mmol·L-1比例、PICU住院时间、总住院时间、脱离PICU时间、24 h内放弃治疗、总放弃治疗差异有统计学意义外,应用血管活性药物在免疫抑制组入PICU 28 d内存活和死亡因素比较中差异有统计学意义。多因素COX比例风险模型分析显示,PRISM Ⅲ评分、有创机械通气、乳酸>2 mmol·L-1是免疫抑制组和免疫健全组入PICU 28 d内病死率的共同危险因素,休克是免疫抑制组入PICU 28 d内病死率的危险因素。结论重症监护室脓毒症患儿病死率较高;伴免疫抑制相关基础疾病的脓毒症患儿病死率更高;PRISMⅢ评分、48 h内有创机械通气和入院乳酸值(>2 mmol·L-1)是其预后的重要危险因素。应建立早期预警指标,对免疫抑制患儿进行早期识别,早期干预,可能改善预后。

Risk factors for 28-day mortality in immunocompromised and immunocompetent pediatric patients admitted to PICU for sepsis: A case-control study

ObjectiveTo analyze the risk factors for 28-day mortality in immunocompromised pediatric patients admitted to PICU for sepsis. MethodsWe conducted a case-control study, and retrospectively collected the clinical data of patients who were admitted to the PICU of Children's Hospital of Fudan University for sepsis. Patients were divided into immunocompetent group and immunocompromised group based on immune status and 28-day mortality was the primary outcome. ResultsFrom December 1st, 2015 to December 31st, 2018, 385 consecutive cases were diagnosed as sepsis at discharge, of which 251 fitted the eligibility criteria, and others were excluded due to ICU-acquired sepsis or being discharged within 24 h. We identified the immunocompetent group (n=141) and immunocompromised group (n=110). The 28-day mortality was 69.1% in immunocompromised patients. Compared with the immunocompetent patients, they showed a larger portion of in-patients, less age disparity and higher PRISM Ⅲ score, and they were more dependent on life support therapies (vasoactive agents, ventilation) and less likely to localize infection sites, the RRT treatment survive rate was 17.4% and none of the 5 ECMO receivers survived. Univariate analysis of 28-day mortality within two groups identified several common factors including septic shock, invasive-ventilation, CRRT, PRISM Ⅲ score, PICU length of stay, hospital stay,PICU-free time, therapy limitation within 24 h and overall therapy limitation, with "other comorbidities" unique to the immunocompetent patients and "vasoactive agents" unique to immunocompromised patients. Multivariate Cox regression revealed that PRISM Ⅲ score, invasive-ventilation and serum lactate above 2 mmol·L-1 were shared risk factors in both groups, and septic shock was also a predictor in the immunocompromised group. Conclusion28-day mortality in pediatric patients admitted to PICU for sepsis remained high, with the immunocompromised status more likely to succumb to death. PRISM Ⅲ score, invasive ventilation and serum lactate above 2 mmol·L-1 were strong predictors for short-term mortality, hence early recognition and effective management might improve patients clinical outcome.