本文選題：兒童 + 重癥監(jiān)護(hù)病房　； 參考：《中南大學(xué)》2012年博士論文

【摘要】：第一部分兒童重癥監(jiān)護(hù)室中膿毒癥患兒發(fā)病情況調(diào)查 目的為了了解兒童重癥監(jiān)護(hù)病房PICU膿毒癥的發(fā)病特點(diǎn)。 方法對2011年4月1日至2011年7月31日入住湖南省兒童醫(yī)院重癥監(jiān)護(hù)病房二區(qū)的1月至18周歲之間的膿毒癥患兒作為研究對象。按照膿毒癥診斷標(biāo)準(zhǔn)篩選病例,符合診斷標(biāo)準(zhǔn)者均納入研究,對其臨床特點(diǎn)、各檢查結(jié)果及預(yù)后的變化,進(jìn)行分析。 結(jié)果本實(shí)驗(yàn)共納入109例膿毒癥患兒,其中普通膿毒癥占53.2%,嚴(yán)重膿毒癥占30.6%,膿毒癥休克者為16.2%。男性占64.9%,女性占35.1%,男女之比為1.85：1。所有患兒中,18%來自城市,82%來自農(nóng)村。年齡最小者30天,最大者10歲,中位數(shù)年齡為294天,1月至3月齡者占17.1%,3月至6月齡者有15.3%,6月齡至1歲者占23.4%,1歲內(nèi)患兒累計占55.9%,1歲至2歲患兒占31.2%。66例有病原學(xué)培養(yǎng)結(jié)果：血培養(yǎng)陽性者16例(14.7%),其中9例為革蘭氏陰性菌感染,7例(45.9%)為革蘭氏陽性菌感染。痰培養(yǎng)陽性者59例(54.1%),其中最常見的是肺炎克雷伯桿菌(12例)及肺炎鏈球菌(10例)。其原發(fā)病灶最常見的為呼吸系統(tǒng)疾病,占64.9%,其次為顱內(nèi)感染及敗血癥。膿毒癥的死亡率為21.6%,其死亡率及總費(fèi)用隨著膿毒癥的嚴(yán)重程度的增加呈上升趨勢。而死亡組與存活組比較,雖總費(fèi)用并無顯著差異,但前者住院時間較后者短,日平均費(fèi)用明顯增加(P=0.005)。經(jīng)多因素回歸分析發(fā)現(xiàn),重癥膿毒癥不良預(yù)后的危險因素包括：PCIS評分、降鈣素原、PF比值、胱抑素C。 結(jié)論1.膿毒癥在PICU中非常常見,以嬰幼兒為主,主要病因?yàn)楹粑到y(tǒng)疾病。體液培養(yǎng)以革蘭氏陰性菌為主。血培養(yǎng)陽性率低,痰培養(yǎng)陽性率較高。2.膿毒癥患兒的死亡率及總費(fèi)用均隨著膿毒癥的嚴(yán)重程度呈上升趨勢,死亡患兒的日平均費(fèi)用較存活組明顯增高。3. PCIS評分、降鈣素原、PF比值、胱抑素c是膿毒癥死亡相關(guān)危險因素。 第二部分兒童重癥監(jiān)護(hù)病房中膿毒癥急性腎損傷的臨床觀察 目的為了了解湖南省兒童醫(yī)院重癥監(jiān)護(hù)病房中(PICU)膿毒癥AKI患兒臨床特點(diǎn)及其檢查指標(biāo)的變化,通過比較膿毒癥AKI組及膿毒癥非AKI組臨床資料、預(yù)后等,探討其異同點(diǎn)。 方法觀察自2011年4月1日至2011年7月31日期間入住PICU的30天至18歲的膿毒癥患兒,建立統(tǒng)一的調(diào)查表,自患兒入ICU至其出院第28天或死亡當(dāng)日作為觀察時間。入PICU時,入住PICU第3天及第7天留取患兒血、尿標(biāo)本送檢。按照急性腎損傷網(wǎng)絡(luò)(AKIN)制定的AKI診斷標(biāo)準(zhǔn),將其分為膿毒癥AKI組及膿毒癥非AKI組。每日觀察患兒病情,所有資料如實(shí)填入統(tǒng)一調(diào)查表。 結(jié)果納入的109例患兒中,其中17例因缺乏36-48小時血肌酐值而無法判斷其肌酐變化。余下92例患者以肌酐變化作為診斷標(biāo)準(zhǔn)診斷AKI患兒32例(34.78%)。其中因尿少診斷為AKI者僅1例。而膿毒癥、嚴(yán)重膿毒癥及膿毒癥休克患者其AKI的發(fā)病率分別為：19.15%(9/47),30%(9/30),93.3%(14/15)。隨著膿毒癥嚴(yán)重程度的增加,其發(fā)病率明顯上升,其OR值為4.414(95%的可信區(qū)間為1.737-11.216),提示膿毒癥是AKI發(fā)生的獨(dú)立危險因素。各組的死亡率分別為2.12%(1/47),23.3%(7/30),46.7%(7/15)。所有AKI患兒中,AKI1期者8例,AKI2期者11例,AKI3期者13例。將膿毒癥AKI組(32例)與膿毒癥非AKI組(60例)進(jìn)行比較,其性別、城鄉(xiāng)、血培養(yǎng)、痰培養(yǎng)、其他培養(yǎng)及尿常規(guī)值之間無明顯差異。而兩組間預(yù)后、進(jìn)行機(jī)械通氣的人數(shù)及膿毒癥嚴(yán)重程度之間有顯著性差異。兩組間比較,其PCIS評分、第3d血肌酐值、入院時尿素氮、心肌酶(肌酸激酶及其同工酶、乳酸脫氫酶)、血小板、降鈣素原、碳酸氫根及二氧化碳分壓之間均有顯著性差異。膿毒癥AKI組住PICU時間、總費(fèi)用也較膿毒癥非AKI組明顯增加,均有顯著差異。而住院時間、平均日費(fèi)用及其他臨床檢查指標(biāo)間均無明顯差異。 結(jié)論根據(jù)膿毒癥急性腎損傷診斷標(biāo)準(zhǔn),膿毒癥急性腎損傷的發(fā)病率為34.78%。膿毒癥AKI的發(fā)生率及死亡率隨著病情嚴(yán)重程度及膿毒癥的嚴(yán)重程度的增加呈上升趨勢。膿毒癥AKI與膿毒癥非AKI組比較,其住PICU時間及總費(fèi)用明顯增加,所需的醫(yī)療資源投入明顯增多。兩者臨床檢查資料多個指標(biāo)也有明顯差異,腎損傷與其他臟器損傷之間有密切聯(lián)系,提示多臟器功能損傷的機(jī)制可能相似。 第三部分膿毒癥腎損傷相關(guān)指標(biāo)間的聯(lián)系 目的探討早期診斷AKI生物標(biāo)記物CysC, KIM-1, NGAL與膿毒癥AKI診斷及其預(yù)后的關(guān)系。 方法本研究選擇2011年4月1日至2011年7月31日入住湖南省兒童醫(yī)院重癥監(jiān)護(hù)病房二區(qū)的1月至18周歲之間的膿毒癥患兒作為研究對象。按照膿毒癥及急性腎損傷的診斷標(biāo)準(zhǔn)篩選病例,納入研究者分為膿毒癥AKI組和膿毒癥非AKI者。通過觀察比較Cys C、KIM-1及NGAL等指標(biāo)在膿毒癥AKI的診斷及其預(yù)后等方面的特點(diǎn)。分析其診斷能力及預(yù)測能力。 結(jié)果經(jīng)過分析比較發(fā)現(xiàn)在膿毒癥AKI診斷方面,Cys C、KIM-1、血NGAL及尿NGAL水平均在入院時即有明顯升高,較血肌酐更早的預(yù)測膿毒癥AKI的發(fā)生,此外,以上指標(biāo)在預(yù)測膿毒癥AKI預(yù)后方面也是比較好的指標(biāo)。Cys C診斷膿毒癥AKI的ROC曲線下面積(AUC)分別為0.927,cutoff值為1.045,超過此值時診斷為膿毒癥AKI的敏感度為86.5%,特異度為93.8%。在預(yù)測膿毒癥AKI的預(yù)后方面,其AUC高達(dá)0.815,Cutoff值為2.805mg/l,超過此值時其敏感度及特異度分別為80%,83.1%。尿KIM-1診斷膿毒癥AKI的AUC0.852,其Cutoff值為20.47ng/l,超過此值時診斷為膿毒癥AKI的敏感度高達(dá)90.7%,特異度72.5%。其預(yù)測膿毒癥AKI的ROC曲線下面積為0.799(95%CI為0.687-0.910,P0.001)。Cutoff值為33.4ng/l,此時敏感度及特異度分別為76.9%、72.9%。血NGAL (pNGAL)診斷及預(yù)測膿毒癥AKI的AUC分別為0.931、0.815,兩者的Cutoff值分別為63.61pg/ml及134.61pg/ml,超過此值時診斷為膿毒癥AKI的敏感度高達(dá)87.5%,特異度86.6%,預(yù)測其預(yù)后的敏感度及特異度分別為85.7%,66.2%。尿NGAL (uNGAL)診斷及預(yù)測膿毒癥AKI的AUC分別為0.906、0.808,兩者的Cutoff值分別為65.88pg/ml,80.37pg/ml,超過此值時診斷為膿毒癥AKI的敏感度高達(dá)74.2%,特異度為96.8%,預(yù)測其預(yù)后的敏感度及特異度分別為83.3%,86%。各指標(biāo)與第3天血肌酐值呈不同程度的正相關(guān)(相關(guān)系數(shù)自0.330至0.585,P0.05),比較發(fā)現(xiàn)血檢結(jié)果與血肌酐的相關(guān)性較尿檢結(jié)果更高,前者多為腎小球功能,而后者多反映的是腎小管功能。綜合分析比較后發(fā)現(xiàn)各指標(biāo)在膿毒癥的診斷及預(yù)測方面各有優(yōu)點(diǎn)。 結(jié)論膿毒癥腎損傷在兒童重癥監(jiān)護(hù)室中的發(fā)病率高,肌酐及尿量作為其診斷指標(biāo)敏感性低。胱抑素C、尿KIM-1、血尿NGAL均可作為AKI的早期診斷指標(biāo),較血肌酐可提前36h。且與膿毒癥AKI的預(yù)后有關(guān)。各指標(biāo)與第3天血肌酐均呈顯著正相關(guān)。血檢結(jié)果與尿檢結(jié)果具有差異,AKI也應(yīng)從腎小球功能、腎小管功能等多方面闡述。
[Abstract]:Investigation on the incidence of sepsis in children with severe sepsis in the first part

Objective To study the pathogenesis of PICU sepsis in children intensive care unit .

Methods From April 1 , 2011 to July 31 , 2011 , children with sepsis between January and 18 in the intensive care unit of Hunan Children ' s Hospital were studied . According to the criteria for diagnosis of sepsis , the patients with sepsis were enrolled in the study . The clinical characteristics , the results of each examination and the changes of prognosis were analyzed .

Results There were 109 patients with sepsis , of whom common sepsis accounted for 53.2 % , severe sepsis accounted for 36.6 % , and septic shock was 16.2 % . Among them , 18 % came from cities and 82 % were from rural areas .

Conclusion 1 . The sepsis is very common in PICU , mainly due to respiratory diseases , mainly due to respiratory diseases . The positive rate of blood culture is low , the positive rate of sputum culture is higher . 2 . The mortality and total cost of children with sepsis are increasing with the severity of sepsis . PCIS score , calcitonin antigen , PF ratio , cystatin c are the risk factors associated with the death of sepsis .

Clinical observation of acute renal injury in children with sepsis in the second part

Objective To study the clinical characteristics of AKI in children in intensive care unit ( PICU ) in children ' s hospital of Hunan Province and the changes of their indexes , and to explore the similarities and differences between AKI group and non - AKI group of sepsis .

Methods A unified questionnaire was established from April 1 , 2011 to July 31 , 2011 for children with sepsis from 30 days to 18 years of PICU . Blood samples and urine samples were collected from children from ICU to discharge day 28 or day of death . In PICU , the children were divided into sepsis AKI group and non - AKI group according to AKI standard established by AKIN .

Results Among the 109 children , 17 of them were not able to judge their creatinine changes due to the lack of serum creatinine values of 36 - 48 hours . Among the remaining 92 cases , the incidence of AKI was 19.15 % ( 9 / 47 ) , 23 . 3 % ( 7 / 30 ) and 46.7 % ( 14 / 15 ) .

Conclusions According to the criteria of acute renal injury in sepsis , the incidence and mortality of septic acute renal injury were 34.78 % . The incidence and mortality rate of septic AKI increased with the severity of the disease and the severity of sepsis . Compared with non - AKI group , there was a significant increase in PICU time and total cost .

Association between indexes related to renal impairment in third part of sepsis

Objective To investigate the relationship between AKI and AKI in early diagnosis of AKI biomarker .

Methods The diagnosis and prognosis of septic patients with sepsis and acute renal injury were selected from Jan . 1 , 2011 to July 31 , 2011 in children from January to 18 , 2011 in the intensive care unit of children ' s hospital in Hunan Province .

Results Compared with AKI in sepsis , the sensitivity and specificity of cystatin AKI in sepsis AKI were 0 . 27 and 1 . 45 mg / l , respectively . The sensitivity and specificity of AKI in the diagnosis and prediction of sepsis were 83.7 % and 0.808 respectively . The sensitivity and specificity of AKI in diagnosis and prediction of sepsis were 85.3 % and 86.2 % , respectively .

Conclusion The incidence of sepsis kidney injury in children ' s intensive care unit is high , the sensitivity of creatinine and urine volume is low as the diagnostic index of AKI . The serum creatinine can be advanced 36h as an early diagnosis index of AKI . It is related to the prognosis of sepsis AKI . The results of blood test are different from the results of urine examination , and AKI should also be explained in many aspects , such as glomerulus function and renal tubules function .

【學(xué)位授予單位】：中南大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2012
【分類號】：R720.597

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本文編號：1866445