危重症儿童血液净化治疗:一项大型单中心八年回顾性研究

Blood purification in critically ill children:a large single-center eight-year retrospective study

目的比较一家三甲儿童专科医院PICU内8年期间行血液净化治疗患儿特征和血液净化技术运行特征,以分析华东部分区域儿童血液净化技术发展过程。方法采用回顾性队列研究,纳入2014至2021年在复旦大学附属儿科医院PICU接受血液净化治疗的所有患儿,分为2014至2017年和2018至2021年两个研究时期,收集并分析纳入患儿的基本信息、临床特征、治疗参数及预后。结果共有1029例患儿纳入研究,其中103例合并使用体外膜肺氧合治疗。单纯血液净化治疗患儿926例,其28 d存活率为55.7%。死亡组中年龄小、体重低、使用机械通气、血液净化前使用血管活性药物和合并多器官功能障碍综合征的患儿比例高于存活组,差异有统计学意义(P<0.05)。8年共行血液净化3688例次,主要采取模式是连续静-静脉血液透析滤过(CVVHDF)(68.6%),其次为血浆置换(TPE)(23.8%)和血液灌流(HP)(4.8%);主要的适应证为急性肾损伤(AKI)(29.3%),其次为严重炎症性疾病(26.2%)和急性肝衰竭(16.2%)。相较于2014至2017年,2018至2021年血液净化治疗次数增加47.4%,患儿存活率明显升高(48.7%比58.1%,P<0.05)。血液净化模式分布和适应证分布亦发生变化(P<0.05)。其中TPE(20.5%比26.0%)和HP(3.1%比6.0%)比例较前增加,而CVVHDF(71.9%比66.4%)比例较前明显下降。适应证中的AKI(29.8%比38.9%)和难治性免疫性疾病(8.4%比15.2%)比例明显升高,而严重炎症性疾病(29.2%比24.2%)和急性肝衰竭(19.6%比13.8%)比例有所下降。结论2014至2021年本中心前后两个阶段比较血液净化开展明显增加,适应证和模式分布亦发生明显变化,总体存活率明显提高。然而在发展中仍需要加强规范化的实践。

Objective To compare the characteristics of patients undergoing blood purification treatment in PICU of a children′s tertiary hospital during 8 years,so as to analyze the changes in the development of blood purification technology in children in East China.Methods Patients who received blood purification treatment in PICU of Children′s Hospital of Fudan University from 2014 to 2021 were included and divided into two study periods:2014-2017 and 2018-2021.The clinical characteristics and treatment parameters of patients were collected and analyzed.Results A total of 1029 patients were included in the study,of which 103 were combined with extracorporeal membrane oxygenation.The 28-day survival rate of 926 patients treated with pure blood purification was 55.7%.Among them,patients with younger age,lower body weight,using mechanical ventilation,using vasoactive drugs before blood purification,and patients with multiple organ dysfunction syndrome had a higher distribution in the death group than those in survival group(P<0.05).During 8 years,a total of 3688 cases of blood purification were performed.The main mode was continuous veno-venous hemodiafiltration(CVVHDF)(68.6%),followed by therapeutic plasma exchange(TPE)(23.8%)and hemoperfusion(HP)(4.8%);the main indication was acute kidney injury(AKI)(29.3%),followed by severe inflammatory disease(26.2%)and acute liver failure(16.2%).Compared with 2014-2017,the number of blood purification treatments in 2018-2021 increased by 47.4%,and the survival rate of patients increased significantly(48.7%vs.58.1%,P<0.05).The distribution of blood purification patterns and indications also changed(P<0.05).The proportions of TPE(20.5%vs.26.0%)and HP(3.1%vs.6.0%)increased,while the proportion of CVVHDF(71.9%vs.66.4%)decreased significantly.The proportions of AKI(29.8%vs.38.9%)and refractory immune diseases(8.4%vs.15.2%)were significantly higher,while severe inflammatory diseases(29.2%vs.24.2%)and acute liver failure(19.6%vs.13.8%)had declined.Conclusion From 2014 to 2021,the number of blood purifications performed in our center increased significantly.Although the distribution of indications and patterns have also changed significantly,the overall survival rate is significantly improved.However,standardized practice still needs to be strengthened.