儿童重症监护室主动出院患儿的多中心前瞻性队列研究

背景：在中国PICU，患儿主动出院是医生常面对的无奈和棘手的问题。目的：探讨PICU主动出院患儿死亡与存活的临床特征，并分析影响主动出院后死亡的因素。设计：多中心前瞻性队列研究。方法：以2016年8月1日至2017年7月31日华东地区8家儿童专科医院PICU主动出院的连续病例为队列人群，以主动出院后28 d内电话随访的存活和死亡为队列结局终点，采集主动出院患儿人群特征、原因、病种、用于小儿危重病例评分（PCIS）和小儿死亡危险评分（PRISMⅢ）评价的所有参数。采用Logistic风险模型分析主动出院死亡的影响因素。主要结局指标：主动出院后28 d内病死率。结果：8家医院PICU共4 952例进入本文分析，住院病死率56%（279/4 059）。主动出院893例（18.1%）中，男518例（58.0%），女375例。年龄中位数1.4岁；主动出院后28 d内失访3例，死亡550例（61.6%），存活340例。主动出院病例农村占比高于城市(62.2% vs 37.8%)，主动出院后28 d内死亡病例农村占比高于存活病例（65.0% vs 57.8%），差异均有统计学意义；主动出院病例死亡病因感染占49.2%，病因不明、肿瘤、先天畸形和遗传代谢分别约占10%。主动出院病例死亡［8(3,15)］与存活［3(0,7)］PRISMⅢ评分差异有统计学意义。对主动出院死亡与在院死亡病例的临床特征行单因素分析，差异有统计学意义的变量进入Logistic回归分析，主动出院的农村病例较城市病例死亡风险增加55%（OR=1.554，95%CI：1.112~2.173，P=0.01）、无医疗保险病例较有医疗保险病例死亡风险增加169%（OR=2.686，95%CI：1.910~3.778，P=0.000）；院前有心肺复苏史的患儿出院死亡风险降低53%（OR=0.467，95%CI：0.271~0.802，P=0.006），PRISMⅢ每降低1分，出院死亡风险降低4%（OR=0.962，95%CI：0.946~0.978，P=0.000）。结论：中国华东8家医院PICU狭义病死率56%，广义的病死率16.8%（829/4 959）；居住地为农村、无医疗保险增加了主动出院死亡风险。院前有心肺复苏史能降低主动出院的死亡风险。

Antimicrobial lock technique in reducing the risk of catheter-related bloodstream infections for children with central venous access devices: A systematic review and meta-analysis

Background: In China, it is resigned and difficult for PICU doctors to accept discharge against medical advice. Objective: To explore the clinical characteristics of dead and surviving children who left PICU against medical advice, and analyze the factors influencing the post-discharge death. Design: Multicenter prospective cohort study. Methods: Consecutive patients discharged against medical advice were recruited from PICU of 8 children's specialty hospitals in the East China from August 1, 2016 to July 31, 2017 as the cohort population. The outcome of survival or death according to the telephone follow-up within 28 days after discharge was the cohort's end points. Demographic data, clinical symptoms, reasons for discharge, and evaluation parameters for PCIS and PRISMⅢ were collected. The logistic risk model was used to analyze the influencing factors of post-discharge death. Main outcome measures: Mortality rate within 28 days of children discharged from the PICU against medical advice. Results: A total of 4,952 cases from PICU of 8 hospitals were included into analysis with in-hospital mortality rate of 5.6%(279/4,059). Among the 893 cases(18.1%) discharged from the hospital against medical advice, there were 518 males(58.0%) and 375 females, with a median age of 1.4 years. Three cases were lost to follow-up within 28 days after discharge. In total, 550 cases(61.6%) died and 340 cases survived. The proportion of discharged cases in rural areas was higher than that in cities(62.2% vs 378%), and the proportion of death cases was higher than that of survival cases(65.0% vs 57.8%) in rural areas during the 28-day follow-up. The differences were statistically significant. The main cause of death in discharged cases was infection accounting for 49.2%, followed by unknown causes, tumor, congenital malformation and genetic metabolism accounting for about 10%, respectively. There was a statistically significant difference in the PRISMⅢ scores between death and survival of discharged cases ［8(3,15) vs 3(0,7)］ . A single factor analysis was performed on the clinical characteristics of discharged deaths and hospital deaths. Variables with statistically significant differences were entered into logistic regression analysis. The risk of discharged rural cases was 55% higher than that of urban cases(OR=1.554, 95%CI: 1.112-2.173). The risk of discharged cases without medical insurance increased by 169% compared with those with medical insurance(OR=2.686, 95%CI: 1.910-3.778). The risk of death from hospital discharge was reduced by 53% for children with a history of cardiopulmonary resuscitation before hospitalization(OR=0.467, 95%CI: 0.271-0.802). For every 1 point reduction in the severity of disease score PRISMⅢ, the risk of death from hospital discharge was reduced by 4%(OR=0.962, 95%CI: 0.946-0.978). Conclusion: The fatality rate excluding cases discharged against medical advice in PICU of 8 hospitals in East China was 5.6%(279/4,059), while the general one was 16.8%(829/4,959). Living in rural areas and no medical insurance increased the risk of post-discharge death. A history of cardiopulmonary resuscitation before hospitalization could reduce the risk of death.