血液肿瘤与非肿瘤儿童脓毒症休克的临床特征比较

Comparison of clinical features of septic shock in children with hematological malignancies versus children without malignant tumors

目的探讨儿科重症监护病房血液肿瘤与非肿瘤脓毒症休克儿童临床特征的差异。方法回顾性分析2015年6月至2022年7月入住首都儿科研究所附属儿童医院重症医学科的脓毒症休克儿童的临床资料。根据是否存在血液肿瘤基础疾病,分为血液肿瘤组和非肿瘤组。比较两组临床资料,应用多因素logistic回归模型分析脓毒症休克死亡的相关因素。结果研究共纳入164例脓毒症休克儿童,男97例,女67例,年龄[M(Q_(1),Q_(3))]为3.6(0.8,7.8)岁。血液肿瘤组75例(45.7%),非肿瘤组89例(54.3%)。与非肿瘤组比较,血液肿瘤组年龄较大[6.0(3.6,9.4)比1.2(0.4,4.3)岁,P<0.001]、外科急症占比较低(14.7%比32.6%,P=0.013)、院内感染率较高[48.0%(36/75)比21.3%(19/89),P=0.001]。血液肿瘤组以血行感染为主[58.7%(44/75)],病原体以革兰阴性杆菌居多[46.7%(35/75)],非肿瘤组以呼吸道[40.4%(36/89)]及消化道[28.1%(25/89)]感染为主,病原体以革兰阳性球菌居多22.5%(20/89)。血液肿瘤组与非肿瘤组感染灶(P<0.001)及感染病原(P=0.001)差异均有统计学意义。血液肿瘤组抗细菌药物种类、去甲肾上腺素应用均高于非肿瘤组(均P<0.05)。与非肿瘤组相比,血液肿瘤组多器官功能障碍综合征发生率[100.0%(75/75)比80.9%(72/89),P<0.001]、28 d病死率[34.8%(23/66)比19.0%(15/79),P=0.048]更高。多因素logistic回归分析显示,血液肿瘤组死亡的相关因素为小儿危重病例评分(OR=1.387,95%CI:1.161~1.657,P<0.001);非肿瘤组死亡的相关因素为小儿危重病例评分(OR=1.419,95%CI:1.140~1.767,P=0.002)、6 h乳酸清除率(OR=65.857,95%CI:2.953~1468.638,P=0.008)。结论血液肿瘤组脓毒症休克患儿年龄更大,以血行感染为主,多器官功能障碍综合征发生率及28 d病死率更高。小儿危重病例评分与儿童脓毒症休克不良预后相关。

Objective To investigate the clinical features of septic shock in children with hematological malignancies compared with those without malignant tumor in the pediatric intensive care unit(PICU).Methods This retrospective study enrolled children with septic shock at the PICU of Capital Institute of Pediatrics′Children′s Hospital from June 2015 to July 2022.According to the presence of hematological malignancies,patients were divided into the hematological malignancies group and without malignant tumor group.Clinical data were compared between the two groups,and logistic regression analysis was used to identify related factors for mortality.Results A total of 164 children(97 males and 67 females)with a median age of 3.6(interquartile range 0.8,7.8)years were enrolled,including 75(45.7%)patients with hematological malignancies and 89(54.3%)patients without malignant tumors.Patients in the hematological malignancies group were older[6.0(3.6,9.4)years vs 1.2(0.4,4.3)years,P<0.001]and more experienced hospital-acquired infections[48.0%(36/75)vs 21.3%(19/89),P=0.001],compared with patients without malignant tumors.Surgical emergencies were more frequent in patients without malignant tumors(32.6%vs 14.7%,P=0.013).Patients with hematological malignancies mainly had blood stream infections(58.7%),with Gram-negative bacilli(46.7%),meanwhile,patients without malignant tumors more experienced Gram-positive cocci infections(22.5%)of the respiratory system(40.4%)or digestive system(28.1%).There were significant differences regarding the infection sites(P<0.001)and pathogens(P=0.001).The types of antibacterial agents(P<0.001)and the frequency of noradrenaline(P=0.013)used in patients with hematological malignancies were significantly higher than those without malignant tumors.Patients with hematological malignancies had a higher incidence of multiple organ dysfunction(MODS)[100.0%(75/75)vs 80.9%(72/89),P<0.001]and higher 28-day mortality[34.8%(23/66)vs 19.0%(15/79),P=0.048].Multivariate logistic regression analysis showed that Pediatric Critical Illness Score(PCIS)was an independent factor for death(odds ratio,OR=1.387,95%CI:1.161-1.657,P<0.001)in patients with hematological malignancies,and PCIS(OR=1.419,95%CI:1.140-1.767,P=0.002)and the 6-hour lactate clearance rate(OR=65.857,95%CI:2.953-1468.638,P=0.008)were independent factors for death in patients without malignant tumors.Conclusions Children with hematological malignancies were older,more frequently experienced bloodstream infections,and had a higher incidence of MODS and higher 28-day mortality.PCIS is related to poor prognosis of septic shock in children.