血小板聚集功能监测在儿童脓毒症中的临床价值

Clinical value of monitoring platelet aggregation function in children with sepsis

目的探讨脓毒症患儿血小板聚集功能水平变化及其与预后的关系。方法采用前瞻性观察性研究方法,选择2017年1月至2018年12月首都儿科研究所附属儿童医院儿童重症监护病房(PICU)收治的53例脓毒症且血小板计数>100×109/L患儿(脓毒症组)及53例同龄行血小板聚集功能检测健康儿童(健康对照组),并比较2组间差异。脓毒症组患儿按小儿危重病例评分(PCIS)分为危重组(评分≤80分)及非危重组(评分>80分);按预后分为存活组和死亡组。并于入院第1、3天行血小板聚集功能检测,并行常规出凝血指标及临床资料记录,比较危重组与非危重组、存活组与死亡组间血小板聚集功能及上述常规出凝血指标有无差异,分析血小板聚集功能与临床预后的相关性。结果脓毒症组和健康对照组性别、年龄比较差异均无统计学意义(均P>0.05)。脓毒症组中非危重组和危重组性别和年龄比较差异均无统计学意义(均P>0.05)。脓毒症组存活44例(83%),死亡9例(17%)。脓毒症组血小板聚集功能显著低于健康对照组(47.4%比79.9%)(P<0.001)。脓毒症组中危重组与非危重症组比较:血小板聚集功能显著降低(32.5%比53.4%,P<0.05);纤维蛋白原(FIB)显著降低(3.28 g/L比4.53 g/L,P<0.05);纤维蛋白(原)降解产物(FDP)显著增高(12.1 mg/L比6.0 mg/L,P<0.05);血小板计数减低(215×10^(9)/L比346×10^(9)/L,P<0.05);凝血酶原时间、活化部分凝血活酶时间、D-二聚体比较差异均无统计学意义(均P>0.05)。死亡组血小板聚集功能显著低于存活组(11.1%比59.7%,P<0.001)。危重组中死亡患儿第1、3天血小板聚集功能持续处于较低水平(11.1%、10.9%),存活患儿第1、3天血小板聚集功能相对处于较高水平(59.7%、65.7%)。血小板聚集功能与FIB、钙离子水平呈正相关(均P<0.05),与PCIS呈正相关(P<0.001)。Logistic回归分析显示血小板聚集功能为脓毒症死亡的影响因素;根据血小板聚集功能所得受试者工作特征曲线,其曲线下面积为0.889(P<0.001),截断值18.3%,灵敏度88.6%,特异度77.8%,当其水平<18.3%时,患儿死亡风险增加。结论脓毒症患儿在血小板计数无减少时已出现血小板聚集功能减低。患儿血小板聚集功能水平与其危重程度相关。脓毒症早期血小板聚集功能减低对患儿不良预后有预警作用。

Objective To investigate the relationship between platelet aggregation function changes in children with sepsis and its prognosis.Methods This was a prospective observational study involving 53 children with sepsis and platelet count of>100×109/L who were admitted in the Pediatric Intensive Care Unit(PICU)of Children′s Hospital Affiliated to the Capital Institute of Pediatrics from January 2017 to December 2018.During the same period,53 age-matched healthy children were selected as the healthy control group.Platelet aggregation function was detected in each participant,and the differences between the two groups were compared.In addition,53 children with sepsis were sub-divided into risk group(≤80 grades)and non-risk group(>80 grades)according to pediatric critical illness scores(PCIS).They were further divided into sepsis survival group and sepsis death group according to the prognosis within 24 hours of admission.Platelet aggregation function test was performed on the 1st and 3rd day of admission,conventional coagulation function and clinical data were detected as well.Their differences between risk group and non-risk group,and sepsis survival group and sepsis death group were compared,so as to analyze the correlation between platelet aggregation function and clinical prognosis of children with sepsis.Results No significant differences in the gender and age were found between sepsis group and the healthy control group(all P>0.05).In sepsis group,no significant differences in the gender and age were found between risk group and non-risk group(all P>0.05).There were 44 cases(83%)in sepsis survival group and 9 cases(17%)in sepsis death group.Platelet aggregation function was significantly worse in sepsis death group than in the healthy control group(47.4%vs.79.9%,P<0.001).Compared with non-risk group,platelet aggregation function in risk group significantly decreased(32.5%vs.53.4%,P<0.05).Fibrinogen(FIB)and platelet count in risk group were significantly lower than those of non-risk group(3.28 g/L vs.4.53 g/L and 215×10^(9)/L vs.346×10^(9)/L,respectively,all P<0.05).Fibrin degradation products(FDP)in risk group was higher than non-risk group(12.1 mg/L vs.6.0 mg/L,P<0.05).There were no significant differences in the prothrombin time,activated partial thromboplastin time and D-Dimer between risk group and non-risk group(all P>0.05).Platelet aggregation function in the death group was significantly lower than that of survival group(11.1%vs.59.7%,P<0.001).On the 1st and 3rd day of admission,platelet aggregation function of died children in risk group continued to be low(11.1%,10.9%),while platelet aggregation function of survival children was relatively high(59.7%,65.7%).Platelet aggregation function was positively correlated with FIB,Ca2+levels and PCIS(P<0.05,P<0.05 and P<0.001,respectively).Logistic regression analysis showed that platelet aggregation function was a contributing factor to the mortality of children with sepsis.According to receiver operating characteristic curve of platelet aggregation function in predicting the mortality of children with sepsis,area under curve was 0.889,cut-off value was 18.3%,sensitivity was 88.6%,and specificity was 77.8%(P<0.001),suggesting that a lower than 18.3%of platelet aggregation function predicted an increased risk of death in children with sepsis.Conclusions In children with sepsis,there is a decrease in platelet aggregation function,while the platelet count has not decreased.Platelet aggregation function in children with sepsis is correlated with the severity of the disease.In detail,reduced platelet aggregation in early sepsis is an alarm of a poor prognosis in children with sepsis.