儿童重症监护室颅内出血临床特点及预后:前瞻性单中心研究

Clinical characteristics and prognosis of pediatric intracranial hemorrhage in pediatric intensive care unit: a prospective and single-center study

目的了解儿童重症监护室(PICU)颅内出血患儿的病因、临床特点和预后,分析不良预后的相关因素,以期为儿童颅内出血的预防和早期预后评估提供依据。方法本研究为前瞻性单中心研究,以2014年10月1日至2017年1月31日入住北京儿童医院PICU的颅内出血患儿为研究对象。记录患儿基本信息,出院28 d电话随访患儿存活情况及通过儿童脑功能分类量表评分(pediatric cerebral performance category score,PCPC)或儿童整体表现分类量表评分(pediatric overall performance category score,POPC)评估预后,分析相关因素与不良预后的关系。结果共纳入患儿95例,男58例,女37例;出院病死率和出院28 d病死率分别为7.4%及22.1%。外伤(68.4%)是引起儿童颅内出血的主要原因。自发性颅内出血的主要原因:婴幼儿期是维生素K缺乏症(4/16例,25.0%),学龄期是血液系统疾病(7/11例,63.6%)。单因素分析显示脑实质出血、脑室出血、硬膜外出血、多部位出血、外伤、血液系统疾病、外科干预、出PICU时低格拉斯哥昏迷评分(GCS)与不良预后相关(χ^2=9.653、10.658、7.237、5.657、10.966、4.471、7.429、31.308,均P<0.05)。多因素分析显示脑室出血、出PICU时低GCS是不良预后的独立危险因素(均P<0.001),外伤患儿较其他出血原因预后相对良好(P=0.015)。结论 PICU颅内出血的患儿以婴幼儿为主,主要病因是外伤。自发性颅内出血的病因婴幼儿期主要是维生素K缺乏症,学龄期主要是血液系统疾病。脑室出血、出PICU时低GCS是不良预后的独立危险因素,外伤较其他出血原因预后相对良好。减少意外伤害是预防儿童颅内出血的关键措施。

Objective To describe the etiology, clinical characteristics and prognosis in children with intracranial hemorrhage who were admitted to pediatric intensive care unit (PICU) and to analyze factors associated with poor prognosis, in order to provide evidence for prevention and early prognosis evaluation. Methods This was a prospective, single-center study including the children with intracranial hemorrhage who were admitted to PICU of Beijing Children′s Hospital from October 1, 2014 to January 31, 2017.Children′s basic information and survival on the 28th day after hospital discharge were collected.Prognosis was evaluated by means of pediatric cerebral performance category score (PCPC) or pediatric overall performance category score (POPC). The related factors with poor prognosis were analyzed. Results Ninety-five children(58 boys and 37 girls) were included;mortality at hospital and on the 28th day after discharge were 7.4% and 22.1%, respectively.Trauma(68.4%) was the most common cause for intracranial hemorrhage(ICH). The most common cause of spontaneous intracranial hemorrhage in infants was vitamin K deficiency (4/16 cases, 0.25), but hematological diseases in school-aged children (7/11 cases, 63.6%). Univariate analysis showed intraparenchymal, intraventricular, extradural hemorrhage.Multiple sites hemorrhage, trauma, hematological system diseases, surgery, and low Glasgow coma scale(GCS) at PICU discharge were associated with poor prognosis(χ^2=9.653, 10.658, 7.237, 5.657, 10.966, 4.471, 7.429, 31.308, all P<0.05). Multivariate analysis showed that intraventricular hemorrhage and low GCS at PICU discharge were independent risk factors for poor prognosis(all P<0.001). ICH caused by trauma had a relatively better prognosis(P=0.015). Conclusions The majority of patients with ICH admitted to PICU are infants.The most common cause is trauma.The most common cause of spontaneous ICH in infants is vitamin K deficiency, but hematological diseases in school-aged children.ICH and low GCS at PICU discharge are independent risk factors for poor prognosis.ICH caused by trauma has a relatively better prognosis.Reducing accidental injury is the key to prevent ICH in children.