脓毒性休克患儿早期临床特点及预后相关因素分析

目的回顾性分析脓毒性休克患儿的早期临床特点及其预后相关危险因素。方法收集2016年1月至2018年11月首都儿科研究所附属儿童医院PICU收治的56例脓毒性休克患儿的临床资料。根据28 d预后情况,分为死亡组和存活组;根据患儿入PICU 24 h内最低小儿危重病例评分(PCIS),分为非危重组(>80分)、危重组(70~80分)及极危重组(<70分),分析比较各组患儿早期的临床特点。结果56例脓毒性休克患儿,平均年龄12.0(1.0,180.0)个月;原发病以呼吸系统感染(60.7%,34/56)为主,病原学以细菌(71.4%,40/56)为主。死亡21例,存活35例,总病死率37.5%;非危重组、危重组和极危重组病死率分别为12.5%(2/16)、16.7%(1/6)、52.9%(18/34)。死亡组与存活组患儿的年龄、性别、PICU住院时间、心率、1 h及24 h平均动脉压、是否使用机械通气及机械通气时间差异无统计学意义(P均>0.05);死亡组患儿的PCIS明显低于存活组,6 h及24 h血管活性药物评分(VIS)明显高于存活组,初始乳酸水平明显高于存活组,1 h、6 h及24 h内入液量明显高于存活组,差异均有统计学意义(P均<0.05)。极危重组患儿的6 h入液量与非危重组比较,差异有统计学意义(P<0.05)。单因素分析显示,PCIS、VIS6 h、VIS24 h、初始乳酸水平及24 h乳酸清除率、降钙素原、射血分数、6 h入液量水平及合并多器官功能障碍(MODS)与患儿死亡有关。多因素Logistic回归分析显示,PCIS、6 h入液量水平、早期乳酸水平及合并MODS是脓毒性休克患儿死亡的独立危险因素。受试者工作特征曲线分析显示,6 h液体入量、PCIS、初始乳酸及MODS预测脓毒性休克患儿死亡的曲线下面积分别是0.947、0.835、0.797、0.761。结论脓毒性休克患儿病死率高,PCIS评分、6 h内复苏液量、早期乳酸水平及合并MODS是患儿死亡的危险因素。

Analysis of early clinical features and prognostic factors of children with septic shock

Objective To explore the early clinical features and the prognostic factors of children with septic shock in PICU.Methods A retrospective analysis was conducted at PICU of the Children′s Hospital,Capital Institute of Pediatrics from January 2016 to November 2018,totally 56 children diagnosed as septic shock were enrolled in the study.According to the prognosis of 28 days,the patients were divided into death group and survival group;according to the lowest pediatric critical score(PCIS)within 24 hours after admission to PICU,the children were divided into non-critical group(>80 points),critical group(70-80 points)and extremely critical group(<70 points).The clinical characteristics of early stage in each group were analyzed and compared.Results Of the 56 children with septic shock,32 were males and 24 were females,and the mean age was 12.0(1.0,180.0)months.The overall mortality rate was 37.5%(21/56).The mortality of non-critical group,critical group and extremely critical group were 12.5%(2/16),16.7%(1/6)and 52.9%(18/34),respectively.There were no statistically significant differences between survival group and death group in gender and age,PICU stay time,heart rate,mean arterial pressure at 1 hour and 24 hours,ventilator using and the duration of mechanical ventilation(all P>0.05).The vasoactive-inotropic score(VIS)at 6 hours and 24 hours of death group were significantly higher than those in survival group19.0(5.0-29.5)vs.5.0(0.0-10.0),22.5(3.5-43.8)vs.5.3(0.0-13.5)].The scores of PCIS in death group were less than that in survival group(57.3±10.7 vs.72.8±12.0)(t=4.85,P<0.001).The lactate level in survival group before resuscitation was statistically lower than that in death group1.8(1.3-2.8)mmol/L vs.4.5(2.4-8.4)mmol/L](Z<-3.70,P<0.05).At 1 hour,6 hours and 24 hours after treatment,fluid resuscitation volume in death group were markedly higher than that in survival group1 hour:(41.8±5.8)ml/kg vs.(38.5±5.3)ml/kg,t=-2.22,P<0.05;6 hours:(69.5±4.4)ml/kg vs.(59.9±3.5)ml/kg,t=-8.96,P<0.05;24 hours:(122.3±19.6)ml/kg vs.(111.7±16.2)ml/kg,t=-2.20,P<0.05].Multiple sample comparisons found significant differences between the non-critical group(60.0±3.5)ml/kg]and the extremely critical group(65.3±6.0)ml/kg,P<0.05],and pairwise comparison of fliud intake within 1 h and 24 h showed no statistically differences(P>0.05).In the univariate analysis,variables significantly associated with death in septic shock were lactic acid before resuscitation and the 24 h lactate clearance rate,VIS6 h,VIS24 h,procalcitonin,ejection fraction,PCIS,6 h-fluid resuscitation volume and multiple organ dysfunction(MODS).The Logistic regression showed that 6 h-fluid resuscitation volume,PCIS,lactic acid and MODS were independent risk factors.ROC curve analysis showed the AUCs of 6 h-fluid resuscitation volume,PCIS,early lactic acid and MODS for predicting death of septic shock children were 0.947,0.835,0.797 and 0.761,respectively.Conclusion The mortality of septic shock is high,and decreased PCIS,elected serum lactic acid level and early fluid resuscitation,and MODS are risk factors associated with the death of septic shock.