床旁超声与生物标志物对儿童脓毒症心肌抑制诊断和脓毒性休克预后的评估价值

The value of bedside ultrasound and biomarkers in the diagnosis of sepsis-induced myocardial dysfunction and prognosis of septic shock in children

目的评价床旁超声和生物标志物对儿童脓毒症心肌抑制的诊断和对脓毒性休克患儿28 d死亡结局的预测效能。方法前瞻性收集2019年1月至2021年7月收入上海交通大学医学院附属上海儿童医学中心重症医学科,符合入选标准并诊断为脓毒性休克的患儿。记录第1、2、3、7、10天床旁超声结果,同时采集血液标本,检测心肌损伤标志物,并记录28 d预后。根据左室射血分数(LVEF)分为心肌抑制组和非心肌抑制组,其中LVEF<50%或较基线水平下降≥10%者定义为心肌抑制,比较组间心脏超声参数和生物标志物的差异。Logistic回归分析发生脓毒症心肌抑制的独立危险因素和脓毒性休克28 d死亡结局的独立危险因素。受试者工作特征曲线评价不同指标对预测脓毒症心肌抑制及脓毒性休克患儿28 d死亡结局的效能。结果共入组57例患儿,心肌抑制组28例,非心肌抑制组29例,单因素分析显示两组的小儿危重病例评分、N末端B型钠尿肽前体(NT-proBNP)、LVEF和左室短轴缩短率差异均有统计学意义(P<0.05)。Logistic回归分析显示LVEF(OR=0.890,95%CI 0.818~0.969,P=0.007)、NT-proBNP(OR=1.000,95%CI 1.000~1.000,P=0.015)是脓毒症心肌抑制的独立危险因素。28 d存活42例,死亡15例。单因素分析显示小儿死亡危险评分Ⅲ、儿童序贯器官功能障碍评分、肌钙蛋白I及二尖瓣环收缩期位移(MAPSE)在存活组和死亡组间差异有统计学意义(P<0.05)。Logistic回归分析显示MAPSE是脓毒性休克患儿28 d死亡结局的独立危险因素(OR=85.670,95%CI 1.685~4356.736,P=0.026)。MAPSE联合肌钙蛋白I及小儿死亡危险评分Ⅲ、儿童序贯器官功能障碍评分(曲线下面积=0.926)相对于单独MAPSE(曲线下面积=0.727)能更好地预测脓毒性休克患儿28 d死亡。结论脓毒症生物标志物NT-proBNP在脓毒症心肌抑制早期明显升高。MAPSE在脓毒症心肌抑制组和非心肌抑制组间无明显差异,但与脓毒性休克患儿预后相关。

Objective To evaluate the feasibility of using bedside ultrasound and serum biomarkers for the prediction of sepsis-induced myocardial dysfunction(SIMD)and mortality in septic shock patients.Methods The patients diagnosed as septic shock were enrolled in the study from January 2019 to July 2021 in PICU at Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine.Bedside ultrasound results were recorded at day 1,2,3,7 and 10.Blood samples were collected at the same time,markers of myocardial injury were detected,and prognosis was recorded at 28 days.According to the left ventricular ejection fraction(LVEF),children with septic shock were divided into SIMD group and non-SIMD group.Those with LVEF<50%or decreased by≥10%from baseline level were defined as SIMD.Differences in cardiac ultrasound parameters and biomarkers between two groups were compared.Logistic regression analysis was performed to determine the independent risk factors for SIMD and the independent risk factors for death at 28 days after septic shock.The area under the receiver operating characteristic curve(AUC)was used to evaluate the efficacy of different indicators in predicting SIMD and the death outcome of children with septic shock on 28 days.Results A total of 57 children were enrolled,including 28 cases in SIMD group and 29 cases in non-SIMD group.Univariate analysis showed that there were statistically significant differences in pediatric critical illness score,N-terminal B-type natriuretic peptide(NT-proBNP),LVEF and left ventricular short axis shortening rate between two groups(P<0.05).Logistic analysis demonstrated that LVEF(OR=0.890,95%CI 0.818-0.969,P=0.007)and NT-proBNP(OR=1.000,95%CI 1.000-1.000,P=0.015)could independently predict SIMD.There were 42 cases in survival group and 15 in non-survival group according to the prognosis on 28 days.Univariate analysis showed that there were significant differences in pediatric risk mortality scoreⅢ,pediatric sequential organ failure assessment,cardiac troponin I,and mitral annular plane systolic excursion(MAPSE)(P<0.05).Logistic analysis showed that only MAPSE independently predicted mortality(OR=85.670,95%CI 1.685-4356.736,P=0.026).Compared with MAPSE(AUC=0.727),MAPSE combined with pediatric risk mortality scoreⅢ,pediatric sequential organ failure assessment,cardiac troponin I(AUC=0.926)could be better to predict the 28 days prognosis of patients with septic shock on 28 days.Conclusion NT-proBNP increases significantly in the early stage of SIMD.MAPSE shows no difference between SIMD and non-SIMD patients.MAPSE is correlated with the prognosis of patient with septic shock.