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

【摘要】：第一部分兒童重癥監(jiān)護室中膿毒癥患兒發(fā)病情況調查 目的為了了解兒童重癥監(jiān)護病房PICU膿毒癥的發(fā)病特點。 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。按照膿毒癥診斷標準篩選病例,符合診斷標準者均納入研究,對其臨床特點、各檢查結果及預后的變化,進行分析。 結果本實驗共納入109例膿毒癥患兒,其中普通膿毒癥占53.2%,嚴重膿毒癥占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%來自農村。年齡最小者30天,最大者10歲,中位數年齡為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歲內患兒累計占55.9%,1歲至2歲患兒占31.2%。66例有病原學培養(yǎng)結果：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疾病,占64.9%,其次為顱內感染及敗血癥。膿毒癥的死亡率為21.6%,其死亡率及總費用隨著膿毒癥的嚴重程度的增加呈上升趨勢。而死亡組與存活組比較,雖總費用并無顯著差異,但前者住院時間較后者短,日平均費用明顯增加(P=0.005)。經多因素回歸分析發(fā)現,重癥膿毒癥不良預后的危險因素包括：PCIS評分、降鈣素原、PF比值、胱抑素C。 結論1.膿毒癥在PICU中非常常見,以嬰幼兒為主,主要病因為呼吸系統疾病。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用均隨著膿毒癥的嚴重程度呈上升趨勢,死亡患兒的日平均費用較存活組明顯增高。3. PCIS評分、降鈣素原、PF比值、胱抑素c是膿毒癥死亡相關危險因素。 第二部分兒童重癥監(jiān)護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)護病房中(PICU)膿毒癥AKI患兒臨床特點及其檢查指標的變化,通過比較膿毒癥AKI組及膿毒癥非AKI組臨床資料、預后等,探討其異同點。 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,建立統一的調查表,自患兒入ICU至其出院第28天或死亡當日作為觀察時間。入PICU時,入住PICU第3天及第7天留取患兒血、尿標本送檢。按照急性腎損傷網絡(AKIN)制定的AKI診斷標準,將其分為膿毒癥AKI組及膿毒癥非AKI組。每日觀察患兒病情,所有資料如實填入統一調查表。 結果納入的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準診斷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。而兩組間預后、進行機械通氣的人數及膿毒癥嚴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、平均日費用及其他臨床檢查指標間均無明顯差異。 結論根據膿毒癥急性腎損傷診斷標準,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重程度及膿毒癥的嚴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也有明顯差異,腎損傷與其他臟器損傷之間有密切聯系,提示多臟器功能損傷的機制可能相似。 第三部分膿毒癥腎損傷相關指標間的聯系 目的探討早期診斷AKI生物標記物CysC, KIM-1, NGAL與膿毒癥AKI診斷及其預后的關系。 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準篩選病例,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等指標在膿毒癥AKI的診斷及其預后等方面的特點。分析其診斷能力及預測能力。 結果經過分析比較發(fā)現在膿毒癥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,較血肌酐更早的預測膿毒癥AKI的發(fā)生,此外,以上指標在預測膿毒癥AKI預后方面也是比較好的指標。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%。在預測膿毒癥AKI的預后方面,其AUC高達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90.7%,特異度72.5%。其預測膿毒癥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87.5%,特異度86.6%,預測其預后的敏感度及特異度分別為85.7%,66.2%。尿NGAL (uNGAL)診斷及預測膿毒癥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74.2%,特異度為96.8%,預測其預后的敏感度及特異度分別為83.3%,86%。各指標與第3天血肌酐值呈不同程度的正相關(相關系數自0.330至0.585,P0.05),比較發(fā)現血檢結果與血肌酐的相關性較尿檢結果更高,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)現各指標在膿毒癥的診斷及預測方面各有優(yōu)點。 結論膿毒癥腎損傷在兒童重癥監(jiān)護室中的發(fā)病率高,肌酐及尿量作為其診斷指標敏感性低。胱抑素C、尿KIM-1、血尿NGAL均可作為AKI的早期診斷指標,較血肌酐可提前36h。且與膿毒癥AKI的預后有關。各指標與第3天血肌酐均呈顯著正相關。血檢結果與尿檢結果具有差異,AKI也應從腎小球功能、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 .

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

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