儿童脓毒症相关性脑病的临床特征及危险因素分析

Clinical features and risk factors of sepsis associated encephalopathy in children

目的探讨儿童脓毒症相关性脑病(SAE)的临床特征及危险因素。方法选取2017年1月至2019年12月于苏州大学附属儿童医院儿科重症监护病房收治的133例脓毒症患儿为研究对象,根据是否发生SAE将其分为SAE组(n=67)和非SAE组(n=66)。比较两组患儿的基本情况与临床特征,分析影响SAE发生的危险因素;采用受试者工作特征(ROC)曲线评价Glasgow昏迷评分(GCS)和第三代小儿死亡危险评分(PRISMⅢ)对SAE的预测效能。结果SAE组28天病死率显著高于非SAE组(χ^(2)=20.428,P<0.001),GCS评分和小儿危重病例评分(PCIS)低于非SAE组(Z值分别为-9.448和-5.720,P<0.001),PRISMⅢ评分高于非SAE组(t=-8.089,P<0.001)。SAE组接受有创机械通气、发生超高热(T>41.0℃)、抽搐/昏迷、休克、呼吸衰竭、心力衰竭、弥散性血管内凝血(DIC)、电解质紊乱和多脏器功能不全综合征(MODS)显著高于非SAE组(P<0.05)。SAE组C反应蛋白、纤维蛋白原和pH低于非SAE组(Z/t值分别为-1.966、3.518、-4.980,P<0.05),而凝血酶原时间、活化部分凝血活酶时间、丙氨酸氨基转移酶、天门冬氨酸氨基转移酶、尿素氮、血肌酐、尿酸、乳酸均高于非SAE组(Z/t值分别为-4.813、-3.533、-2.394、-4.052、-3.152、-2.763、-3.335、-4.157,P<0.05)。多因素Logistic分析显示,脓毒症患儿发生休克(OR=2.717,95%CI:1.512~7.014)、需要有创通气(OR=5.285,95%CI:2.815~13.145)、较高的PRISMⅢ评分(OR=1.145,95%CI:1.006~1.303)、较低的GCS评分(OR=0.280,95%CI:0.149~0.527)者,其发生SAE的风险较大。ROC分析显示,GCS联合PRISMⅢ评分对SAE具有较好的预测价值(AUC=0.978,95%CI:0.955~1.000)。结论SAE患儿具有更加严重的器官功能损害和更高的病死率。脓毒症患儿休克、需要有创通气、较低的GCS评分、较高的PRISMⅢ评分是发生SAE的危险因素。

Objective To analyze clinical features of sepsis associated encephalopathy(SAE)in children.Methods The clinical data of 133children with sepsis who admitted to Pediatric Intensive Care Unit(PICU)of The Affiliated Children′s Hospital of Soochow University from January 2017to December 2019were reviewed.According to whether the child developed SAE,the children were divided into SAE group(67cases)and non-SAE group(66cases).The general information and clinical features of the children were compared between the two groups,and the risk factors of SAE were analyzed.The receiver operator characteristics(ROC)curve was used to evaluate predicting effects of Glasgow coma score(GCS)and pediatric risk of mortalityⅢscore(PRISMⅢ).Results The mortality rate at 28-day after birth in the SAE group was 52.24%,which was significantly higher than 15.15%in the non-SAE group(χ^(2)=20.428,P<0.001).The GCS and pediatric critical illness score(PCIS)of the children in the SAE group were lower than those in the non-SAE group(Z=-9.448and-5.720respectively,both P<0.001),while their PRISMⅢscore was higher than that in the non-SAE group(t=-8.089,P<0.001).The use rate of invasive mechanical ventilation and the inci-dence rates of ultrahyperpyrexia(T>41.0℃),convulsion/coma,shock,respiratory failure,cardiac failure,diffuse intravascular co-agulation(DIC),electrolyte disturbance and multiple organ dysfunction syndrome(MODS)in the SAE group were all significantly higher than those in the non-SAE group(all P<0.05).The serum levels of prothrombin time(PT),activated partial thromboplastin time(APT),alanine aminotransferase(ALT),aspartate aminotransferase(AST),urea nitrogen(UREA),serum creatinine(CREA),uric acid(UA)and lactic acid(LA)of the children in the SAE group were higher than those of the children in the non-SAE group(Z/t=-4.813,-3.533,-2.394,-4.052,-3.152,-2.763,-3.335and-4.157respectively,all P<0.05),while their serum levels of C-reactive protein(CRP),fibrinogen(Fib)and PH value were lower than those in the non-SAE group,the differences were statistically significant(Z/t=-1.966,3.518and-4.980respectively,all P<0.05).Single factor Logistic re-gression analysis showed that need for invasive ventilation,electrolyte disturbance,DIC,shock,respiratory failure,serum levels of LA,PH,Fib,PT,APTT,UA and Alb,GCS,PCIS and PRISMⅢscore were related to occurrence of SAE in children(OR=6.391,2.149,3.848,3.494,3.189,1.287,0.001,0.703,1.015,1.056,1.001,0.950,1.171,0.917and 0.290respectively,all P<0.05).Multivariate Logistic regression analysis showed that those children with shock(OR=2.717,95%CI:1.512-7.014),who needed for invasive mechanical ventilation(OR=5.285,95%CI:2.815-13.145),had high PRISMⅢscore(OR=1.145,95%CI:1.006-1.303)and low GCS(OR=0.280,95%CI:0.149-0.527)had high risk of SAE.ROC analysis showed that GCS combined with PRISMⅢscore had a good predictive value for SAE(AUC=0.978,95%CI:0.955-1.000).Conclusion Those children with sepsis who develop SAE have more severe organ damage and a higher mortality rate.In the children with sepsis,shock,need for invasive mechanical ventilation,GCS lower than 10.5and PRISMⅢscore higher than 20.5are independent risk factors for SAE.