62例小儿危重急腹症术后临床分析

Clinical Analysis of 62 Cases of Children's Severe Acute Abdominal Postoperation in PICU

目的：评估急腹症患儿腹部术后入儿科重症监护室（PICU）的预后及腹腔感染抗生素治疗情况，从而判断患儿预后，提高救治成功率。方法：收集2010年1月至2011年12月因急腹症腹部外科术后进入PICU的62例患儿的临床资料，回顾性分析患儿预后指标，总结治疗经验。根据小儿危重症评分将患儿分成一般危重组（81～90分）、危重组（71～80分）、极危重组（≤70分），分析比较其血清白蛋白、前白蛋白水平及患儿滞留ICU时间，并了解腹部外科疾病腹腔感染病原菌种类及抗生素使用情况。结果：根据小儿危重症评分，一般危重组36例，危重组21例，极危重组5例，血清白蛋白水平分别为（34．38±3．56）g／L、（30．56±6．57）g／L、（33．12±2．61）g／L，三组比较差异无统计学意义（P〉0．05）；前白蛋白水平分别为（145．70±40．57）mg／L、（102．90±16．41）mg／L、（96．73±16．85）mg／L，差异有统计学意义（P〈0．01）；三组滞留ICU时间分别为（1．79±1．66）d、（5．66±2．64）d,9d，差异有统计学意义（P〈0．01）。前白蛋白与危重症评分、滞留PICU时间的相关性高于白蛋白（r分别为0．6520及0．4506、0．4473及旬．5387），差并有统计学意义（P〈0．05）。送检标本共71份，分离细菌21例，其中革兰阴性杆菌15株，感染率为71．43％，革兰阳性菌6株，感染率为28．57％。根据临床经验抗菌药物首选为亚胺培南一西司他丁钠（秦能）、去甲万古霉素、甲硝唑。结论：危重症评分越低，前白蛋白水平越低，患儿滞留ICU时间更长。血清前白蛋白水平对患儿预后评估比白蛋白更敏感，可作为病情严重度监测的辅助性指标。患儿腹部外科疾病腹腔感染仍以革兰阴性杆菌为主，但革兰阳性菌感染有增多趋势，故抗菌药物选择应兼顾革兰阴性菌和革兰阳性菌。

Objective： To evaluate the outcome of children after operation for severe acute abdomen in podiatric intensive care unit （PICU）, and to assess the effect of prognosis. Methods： Clinical data of sixty-two cases of acute abdomen after operation in PICU from January 2010 to December 2011 were analyzed. According to Pediatric Critical Illness Scores （PCIS）, sixty-two cases were divided into three groups： a mild critical group （81 ~90 points）, a critical group （71 -80 points）, and a severe critical group （ ~〈70 points） respectively. The level of albumin （Alb） and prealbumin （Pre-alb） and the duration of staying in PICU were observed. The pathogenic bacteria and the use of antibiotics were analyzed. Results： According to the PCIS, the numbers of cases of mild critical, critical and severe critical group were 36, 21 and 5, respectively. No significant difference of the level of Alb was found in each group （P〉0.05）, while the difference of the level of Pre-alb were found significantly between the three groups （P〈0.01）. The correlation between Pre-alb and Pediatric Critical Illness Scores, the length of PICU stay was better than that between Alb and Pediatric Critical Illness Scores, the length of PICU stay （P〈0.05）. Totally twenty-one pathogenic stains were isolated from seventy-one samples. Among them, fifteen stains were Gram-negative bacilli （71.43%）, six stains were Gram-positive cocci （28.57%）. Imipenem-cilastatin （Taineng）, norvancomycin and metronidazole were selected. Conclusions： The PCIS can be used for grading severity of illness and evaluating prognosis. The level of serum Pre-alb is more sensitive than that of Alb in prognosis assessment ; it can be as an auxiliary index of monitoring the severity of the patient＇s condition. The most common bacteria infection was Gram- negative bacilli, while Gram-positive bacteria infection was increasing. The selection of antibiotics must take into account both.