北京地区两家医院儿科重症监护病房486例脓毒症分析

摘要

目的 通过大样本的前瞻性临床研究,了解北京地区儿科重症监护病房(PICU)脓毒症的患病率、病死率、病因和疾病负担以及预后相关危险因素等.方法 2008年11月1日至2009年12月31日,选取北京地区2家儿童医院的PICU进行调查.对PICU收治的年龄在29 d至18周岁的患儿进行评估,将小儿危重病例评分(PCIS)≤90分或符合美国PICU入院指南的患儿作为PICU危重病例；在危重病例中,按照脓毒症诊断标准筛选出全部脓毒症、严重脓毒症和脓毒性休克患儿,收集资料,使用SPSS软件进行数据比较.结果 2家医院PICU 14个月共收治患儿1531例,其中危重病例1250例.脓毒症、严重脓毒症、脓毒性休克患儿共486例,死亡55例,PICU内总患病率为38.9％(486/1250),病死率为11.3％( 55/486)；其中脓毒症、严重脓毒症、脓毒性休克的患病率分别为25.5％(319/1250),10.3％(129/1250),3.0％(38/1250),病死率分别为2.2％(7/319),23.3％ (30/129),47.4％ (18/38).小于3岁的幼儿占脓毒症患儿总数的75.5％( 367/486).以肺炎为主(63.6％,309/486)的呼吸系统疾病是脓毒症最常见感染性原发病(71.8％,349/486).细菌所致的感染占脓毒症有明确病原学患儿的64.1％,其中G+菌和G-菌感染分别占46.1％和53.9％.PCIS评分分值与脓毒症严重程度呈负相关关系(r=- 0.583,P＜0.01).脓毒症死亡危险因素为评分PCIS分值明显降低和需要使用机械通气支持治疗.PICU中严重脓毒症和脓毒性休克患儿人均住院费用分别是危重患儿的2.3倍和1.3倍.结论 脓毒症是PICU患病率高的常见病；严重脓毒症/脓毒性休克患儿的病死率高,治疗费用高；小于3岁的婴幼儿易患病；肺炎等急性呼吸道疾病为主要感染性原发病、病原以细菌感染为主,其次为病毒感染；PCIS分值明显降低及需要使用机械通气支持治疗是发生死亡的独立危险因素.%Objective To investigate the incidence,mortality,causes and risk factors of sepsis in children in pediatric intensive care units (PICU) in Beijing through large sample prospective clinical research.Methods From 1 st November 2008 to 31 st December 2009,all patients aged from 29 days to 18years admitted to PICU of the two children's hospitals in Beijing were surveyed. Patients who met the conditions of Chinese pediatric critical illness score (PCIS) ＜ 90 or American guidelines for PICU admission were defined as critically ill cases. According to the definitions of sepsis of 2005 international pediatric sepsis consensus conference and 2006 Chinese Medical Association meeting,sepsis,sever sepsis,and septic shock cases were selected from these critically ill patients. The qualified subjects were surveyed by questionnaire until discharge or death the data were analyzed by SPSS.Results A total of 1531 of PICU admissions were enrolled within a 14-month period,of whom 1250 met the criteria of critically ill case; 486developed sepsis,of whom 55 died.The morbidity of sepsis for all in critically ill patients in PICU was 38.9％ (486/1250) and the mortality was 11.3％ (55/486).The morbidity of sepsis,severe sepsis and septic shock in these PICU was 25.5％ (319/1250),10.3％ (129/1250),3.0％ (38/1250) and the mortality was 2.2％ (7/319),23.3％ (30/129),and 47.4％ ( 18/38),respectively.The proportion of less than 3 years old was 75.5％ (367/486). Respiratory system diseases (71.8％),such as pneumonia (63.6％),were the underlying primary infectious diseases of sepsis. Bacterial etiology accounted for 64.1％ of the cases with sepsis with definite etiological test results.The proportion of gram-positive bacteria and gram-negative bacteria were 46.1％ and 53.9％, respectively. PCIS and disease severity were negatively correlated ( r =- 0.583,P ＜ 0.01 ). Multiple stepwise logistic regression analysis showed that depressed PCIS and use of mechanical ventilation were the risk factors for death.Average medical costs per patient in PICU with severe sepsis and septic shock were 2.3 times and 1.3 times higher than those of critically ill patients.Conclusions Sepsis with the characteristics of high morbidity,mortality and cost was one of the critical illnesses in PICU in two pediatric hospitals in Beijing.Patients younger than 3 years were more susceptible to develop sepsis.Main infectious cause was paeumonia and basteria was the main pathogen bacterial pneumonia.Risk factors for death were deuressed PCIS and use of mechanical ventilation.