重症儿童腹腔内高压的高危因素及其对预后的影响

摘要

Objective To investigate the risk factors and prognosis of intra-abdominal hypertension (IAH) in critically ill children.Methods Prospective longitudinal observational study was conducted in two tertiary care university teaching hospital from December 2013 to June 2016.All children consecutively admitted to the PICU,staying more than 24 hours,age ≤ 14 years and requiring bladder catheterization,were included in the study.The intra-abdominal pressure(IAP) was measured every 8 hours through a bladder catheter until discharge or removal of the catheter.On admission,demographic data and risk factors for IAH were studied.Risk factors were analyzed by multiple Logistic regression models.Prognosis was assessed by Kaplan-Meier curves.Results Of the 458 patients,180 (39.3％) had IAH (lAP ＞ 10 mm Hg) during PICU stay.The independent risk factors associated with IAH were abdominal neoplasms (OR 9.7,95％ CI 1.1 ～ 93.8,P =0.04),lactic acid level (OR 2.4,95％ CI 1.1 ～ 5.3,P =0.03) and non-abdominal diseases (OR 0.1,95％ CI 0.1 ～ 0.2,P ＜ 0.001).Obesity,MV and PEEP were not significant factors affecting IAH in children.The duration of MV was not significantly longer in patients with IAH vs.patients without IAH (P ＞ 0.05).Length of the hospital stay (P =0.02) and 60-day mortality rate (P ＜ 0.01) was significantly higher in the IAH group than in the non-IAH group.The IAH and non-IAH survival curves also differed significantly at 60-day (P ＜ 0.001).Conclusion IAH does have high occurrence and mortality rate in critically ill children.Abdominal neoplasms and lactic acid level are independent risk factors of developing IAH.Children with IAH have higher mortality rate and length of the hospital stay.%目的 了解重症儿童腹腔内高压(intra-abdominal hypertension,IAH)发生率及其对预后的影响,探讨导致IAH发生的高危因素.方法 2013-12～ 2016-06开展2个中心儿童重症监护室(pediatric intensive care unit,PICU)前瞻性观察研究,参与研究的2个PICU均属综合性儿童内外科ICU,入组年龄≤14岁、PICU治疗时间＞24 h且期间有留置尿管的患儿,采用膀胱测压法监测腹腔内压力(intra-abdominal pressure,IAP)并记录临床资料;应用单因素和多因素Logistic回归分析筛选IAH高危因素,使用生存曲线评估预后.结果 研究共纳入458例患儿,其中IAH(IAP＞10 mm Hg)为180例(39.3％).腹部肿瘤(OR 9.7,95％ CI 1.1～93.8,P=0.04)、乳酸(OR 2.4,95％ CI1.1～5.3,P=0.03)和非腹部疾病(OR0.1,95％ CI0.1 ～0.2,P ＜0.001)是重症儿童IAH发生的独立危险因素.肥胖、机械通气和呼气末正压(PEEP)对IAH的影响无明显统计学意义.IAH组与非IAH组机械通气时间比较差异无统计学意义(P＞0.05),两组患儿住院时间(P=0.02)及60d病死率比较差异有统计学意义(P＜0.01).两组患儿60 d生存曲线比较差异有统计学意义(P＜0.001).结论 IAH在重症儿童中有较高的发生率,腹部肿瘤、乳酸升高是重症儿童IAH发生的高危因素,IAH患儿住院时间更长、病死率更高.