不同级别医院儿童重症监护病房脓毒性休克患儿诊治现状

Diagnosis and treatment of pediatric septic shock in pediatric intensive care units from hospitals of different levels

目的了解国家级、省级和市级儿童医院儿童重症监护病房脓毒性休克的临床特征及诊疗差异。方法回顾性分析不同级别的3家儿童医院(北京儿童医院、河南省儿童医院、保定市儿童医院)儿童重症监护病房2018年1月至2021年12月收治的368例脓毒性休克患儿的临床资料,包括一般情况、发病地点(社区获得性、院内获得性)、危重程度、病原阳性率、指南依从性(复苏6 h达标率、诊断后1 h内给予抗感染药物率)、治疗情况和住院病死率等。根据医院级别分为国家级、省级和市级3组,根据有无肿瘤和病例来源进一步分为肿瘤组和非肿瘤组、院内转科组和门急诊组。采用χ^(2)检验、Mann-Whitney U检验比较组间差异。结果368例患儿中男223例、女145例,年龄32(11,98)月龄。国家级组215例、省级组107例,市级组46例,男性患儿分别为141、51、31例。3组第3代小儿死亡危险评分(PRISMⅢ)差异有统计学意义[26(19,32)比19(12,26)比12(6,19)分,Z=60.25,P<0.001],社区获得性脓毒性休克比例差异有统计学意义[31.6%(68/215)比84.1%(90/107)比91.3%(42/46),χ^(2)=108.26,P<0.001],指南依从性差异无统计学意义(P>0.05)。国家级组主要检出细菌为肺炎克雷伯菌[15.4%(12/78)]和金黄色葡萄球菌[15.4%(12/78)],省级组为金黄色葡萄球菌[19.0%(12/63)]和铜绿假单胞菌[12.7%(8/63)],市级组为肺炎链球菌[40.0%(10/25)]和肠杆菌[16.0%(4/25)]。国家级、省级和市级组病毒检出率和初始抗细菌药物使用3种及以上占比差异有统计学意义[27.7%(43/155)比14.9%(13/87)比9.1%(3/33),22.8%(49/215)比11.2%(12/107)比6.5%(3/46),χ^(2)=8.82、10.99,均P<0.05]。3组住院病死率差异无统计学意义(P>0.05)。PRISMⅢ评分国家级组在肿瘤、非肿瘤[31(24,38)比22(21,28)比16(9,22)分,24(18,30)比17(8,24)比10(5,16)分,Z=30.34、10.45,均P<0.001]和院内转科、门急诊[29(21,38)比23(17,31)比15(10,29)分,23(17,29)比18(10,24)比11(5,16)分,Z=20.33、14.25,均P<0.001]4个亚组均高于省级组和市级组,但住院病死率各亚组差异均无统计学意义(均P>0.05)。结论不同等级儿童医院脓毒性休克患儿病情危重程度、发病地点、病原谱构成和初始抗感染药物使用等方面均存在一些不同,但指南依从性、住院病死率并无差异。

Objective To investigate the differences in clinical characteristics,diagnosis,and treatment of pediatric septic shock in pediatric intensive care unit(PICU)among hospitals of different levels.Methods This retrospective study enrolled 368 children with septic shock treated in the PICU of Beijing Children′s Hospital,Henan Children′s Hospital,and Baoding Children′s Hospital from January 2018 to December 2021.Their clinical data were collected,including the general information,location of onset(community or hospital-acquired),severity,pathogen positivity,consistence of guideline(the rate of standard attainment at 6 h after resuscitation and the rate of anti-infective drug administration within 1 h after diagnosis),treatment,and in-hospital mortality.The 3 hospitals were national,provincial,and municipal,respectively.Furthermore,the patients were divided into the tumor group and the non-tumor group,and into the in-hospital referral group and the outpatient or emergency admission group.Chi-square test and Mann-Whitney U test were used to analyze the data.Results The 368 patients aged 32(11,98)months,of whom 223 were males and 145 females.There were 215,107,and 46 patients with septic shock,with males of 141,51,and 31 cases,from the national,provincial,and municipal hospitals,respectively.The difference in pediatric risk of mortalityⅢ(PRISMⅢ)scores among the national,provincial and municipal group was statistically significant(26(19,32)vs.19(12,26)vs.12(6,19),Z=60.25,P<0.001).The difference in community acquired septic shock among the national,provincial and municipal group was statistically significant(31.6%(68/215)vs.84.1%(90/107)vs.91.3%(42/46),χ^(2)=108.26,P<0.001).There were no significant differences in compliance with guidelines among the 3 groups(P>0.05).The main bacteria detected in the national group were Klebsiella pneumoniae(15.4%(12/78))and Staphylococcus aureus(15.4%(12/78));in the provincial group were Staphylococcus aureus(19.0%(12/63))and Pseudomonas aeruginosa(12.7%(8/63)),and in the municipal group were Streptococcus pneumoniae(40.0%(10/25))and Enteric bacilli(16.0%(4/25)).The difference in the proportion of virus and the proportion of 3 or more initial antimicrobials used among the national,provincial and municipal group was statistically significant(27.7%(43/155)vs.14.9%(13/87)vs.9.1%(3/33),22.8%(49/215)vs.11.2%(12/107)vs.6.5%(3/46),χ^(2)=8.82,10.99,both P<0.05).There was no difference in the in-hospital mortality among the 3 groups(P>0.05).Regarding the subgroups of tumor and non-tumor,the national group had higher PRISMⅢ(31(24,38)vs.22(21,28)vs.16(9,22),24(18,30)vs.17(8,24)vs.10(5,16),Z=30.34,10.45,both P<0.001),and it was the same for the subgroups of in-hospital referral and out-patient or emergency admission(29(21,39)vs.23(17,30)vs.15(10,29),23(17,29)vs.18(10,24)vs.11(5,16),Z=20.33,14.25,both P<0.001)as compared to the provincial and municipal group.There was no significant difference in the in-hospital mortality among the 2 pairs of subgroups(all P>0.05).Conclusion There are differences in the severity,location of onset,pathogen composition,and initial antibiotics of pediatric septic shock in children′s hospitals of different levels,but no differences in compliance with guidelines and in-hospital survival rate.