上海市四家儿童医院重症监护病房304例脓毒症诊治调查分析

Hospital epidemiology, management and outcome of pediatric sepsis and severe sepsis in 4 PICUs in Shanghai

目的 调查上述4家儿童医院重症监护室脓毒症的收治情况、临床特点以及应用“拯救脓毒症运动”指南的执行情况.方法 设计统一登记表,指定专科医生收录2008年4月至2009年3月上海市复旦大学附属儿科医院、上海市交通大学附属儿童医学中心、上海市儿童医院及上海市新华医院儿科4家PICU病房内收治的脓毒症病例,分析其临床特点,并就其主要诊疗方案与《严重脓毒症和脓毒性休克治疗指南》（儿科部分）进行比较.结果 （1）4家儿童医院PICU共收录符合脓毒症诊断的儿童病例304例,占4家医院ICU同期收治病例（2100例）的14.48％,其中212例（69.74％）直接收住ICU.304例中严重脓毒症118例（38.8％）,平均年龄37个月.男女比例为1.95∶1,存活病例的入院和最低小儿危重评分显著高于死亡病例的评分.（2）所有脓毒性休克患儿接受了液体复苏,22.95％的病例液体复苏不符合《指南》,包括复苏液量不足和过早使用血管活性药物.使用血管活性药物的病例中30％未诊断脓毒性休克,所有病例均未使用去甲肾上腺素或肾上腺素.181例（59.54％）入院1h内给予使用抗生素.64例使用了小剂量糖皮质激素,其中39例皮质激素治疗不符合《指南》.只少数病例采用了胰岛素、肝素治疗及使用连续血液净化.（3） 41例患儿死亡（13.5％）,严重脓毒症病例36例死亡（30.51％）,非严重脓毒症病例死亡5例（2.80％）,二者差异有显著统计学意义（P＜0.01）；100例患儿入院危重评分＜ 80分,死亡29例（29％）,占全部死亡病例的70.73％,＞80分的病例死亡12例（5.88％）,占全部死亡病例的29.27％,P＜0.05.放弃病例共46例,占总数15.1％.结论 脓毒症在上海市4家儿童医院重症监护室有较高的收治率.危重评分低及婴幼儿病例具有较高的病死率.儿童危重症的临床治疗与“拯救脓毒症运动”指南比较仍存在一定的差距.

Objective Sepsis is a major healthcare problem in Pediatric intensive Care unit （PICU）.Therapies administrated in the initial hours after sepsis develops are likely to influence outcome.To guide the bedside clinician to improve the outcomes,the Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock was updated in 2008. This study aimed to assess the presentation,severity of disease,intensive care outcome of patients with sepsis admitted to the PICU and evaluate the compliance of implementation of the Surviving Sepsis Campaign guidelines.Methods Medical records of the patients treated for sepsis in PICUs of 4 hospitals including Children＇s Hospital of Fudan University,Shanghai Children＇s Medical Centre,Children＇s Hospital of Shanghai and Shanghai Xinhua Hospital from April 2008 to March 2009 were reviewed retrospectively. Doctors of the Critical Care Centre not involved in the clinical management analyzed the clinical charts and compared the treatment received and how the Surviving Sepsis Campaign implements.Results 1.Out of the 2100 patients admitted to the 4PICUs from April 2008 to March 2009, 304 （14.48%） were diagnosed sepsis, among whom 212（69.74%） children were sent to the PICU directly; 118 （38.8%） cases suffered from severe sepsis,36（30.51% ） of whom died.Five （2.8% ） cases died of sepsis,there was statistically significant difference （P〈0.01）.The median age of the patients was 37 months.The sex ratio （M∶ F） was 1.95∶ 1.The Pediatric Critical Illness Score on admission and the lowest score of the survivors were significantly higher than that of the dead cases.2. All the children suffering from septic shock received fluid resuscitation,22.95% of whom were inappropriate,including no enough fluid administration and too early vasopressor preference; 30% cases treated with vasopressor were not diagnosed septic shock,and no norepinephrine or epinephrine was administrated. Antibiotics were administrated in 181 （59.54% ） cases within 1 hr of admission.Low-dose steroids therapy was given to 64 cases,39 of whom did not suffer from severe sepsis or septic shock.A few cases were treated with insulin,heparin or continuous blood purification.3.Of all the sepsis patients,41 （ 13.5% ） died.Thirty-six children （30.51% ） with severe sepsis and 5 （2.80% ）cases who did not suffer from severe sepsis died,which made significant difference （P 〈 0.01 ） ; 29 （29%）of 100 cases whose Pediatric Critical Illness Score was 〈 80 died,which was 70.73% of all the deaths,and 12 （5.88%） cases whose severity score was 〉80 died,29.27% of all the dead cases （P 〈0.05）.Of allthe cases,46 （ 15.1% ） gave up treatment.Conelusion There is a high proportion of sepsis in patients admitted to the four PICUs in Shanghai.Children who have low Glasgow severity score or in their very young age have a higher mortality rate.The adherence to the Surviving Sepsis Campaign guidelines still needs to be improved.