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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (03) : 292 -299. doi: 10.3877/cma.j.issn.1673-5250.2019.03.009

所属专题： 文献；

论著

尿源性脓毒症患儿的临床特点分析
陈丽妮1, 罗黎力2, 李德渊2, 刘忠强2, 乔莉娜2,†()   
  1. 1. 四川大学华西第二医院儿童重症监护室、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041；四川大学华西临床医学院，成都　610041
    2. 四川大学华西第二医院儿童重症监护室、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041
  • 收稿日期:2019-01-08 修回日期:2019-04-19 出版日期:2019-06-01
  • 通信作者: 乔莉娜

Clinical characteristics of children with urosepsis

Lini Chen1, Lili Luo2, Deyuan Li2, Zhongqiang Liu2, Lina Qiao2,†()   

  1. 1. Pediatric Intensive Care Unit, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China; West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
    2. Pediatric Intensive Care Unit, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2019-01-08 Revised:2019-04-19 Published:2019-06-01
  • Corresponding author: Lina Qiao
  • About author:
    Corresponding author: Qiao Lina, Email:
  • Supported by:
    Project of Sichuan Academic and Technology Leadership Training Support((2017) 919-23); Sichuan Science and Technology Plan Project(2019YFS0245)
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引用本文：

陈丽妮, 罗黎力, 李德渊, 刘忠强, 乔莉娜. 尿源性脓毒症患儿的临床特点分析[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(03): 292-299.

Lini Chen, Lili Luo, Deyuan Li, Zhongqiang Liu, Lina Qiao. Clinical characteristics of children with urosepsis[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(03): 292-299.

目的

探讨尿源性脓毒症患儿的临床特点。

方法

选择2017年1月至2018年6月，在四川大学华西第二医院住院治疗的51例尿源性脓毒症患儿为研究对象，并纳入研究组。按照1∶2的比例，采用Microsoft Excel 2016随机抽取功能，抽取同期在本院住院治疗的102例非尿源性脓毒症患儿纳入对照组。收集2组患儿的一般临床资料、实验室检查指标、脏器功能损害及预后情况。采用独立样本t检验，对2组患儿的血小板计数(PLT)、纤维蛋白原(Fib)和红细胞沉降率(ESR)等进行统计学分析。采用Mann-Whitney U秩和检验，对2组患儿的白细胞计数(WBC)、血红蛋白(Hb)、丙氨酸转移酶(ALT)、天冬氨酸氨基转移酶(AST)、白蛋白、总胆红素(TB)、乳酸脱氢酶(LDH)、肌酐、血尿素氮(BUN)、血糖、D-二聚体(DDI)、纤维蛋白原降解物(FDP)、N端脑钠肽(NTBNP)、肌钙蛋白I (cTnI)、血清pH值与乳酸，以及血清Na＋、K＋、Ca2＋及Cl－等进行统计分析。采用χ2检验或者连续性校正χ2检验，对2组患儿的性别构成比、儿科重症监护病房(PICU)转入率、病死率等计数资料进行统计分析。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。2组患儿性别构成比比较，差异无统计学意义(P>0.05)。

结果

①研究组患儿中位年龄为6个月(4～12个月)，小于对照组的10个月(5～24个月)，差异有统计学意义(Z＝－2.660，P＝0.008)。②研究组患儿的WBC及CRP水平分别为17.4×109/L[(11.8～26.6)×109/L]和120 mg/L(87～160 mg/L)，均明显高于对照组的12.0×109/L[(5.0～17.6)×109/L]和48 mg/L(20～135 mg/L)，2组比较，差异均有统计学意义(Z＝－4.145、－4.465，P均<0.001)。研究组患儿WBC>15×109/L及CRP>40 mg/L所占比例，分别为62.7%(32/51)和90.2%(46/51)，均高于对照组的38.2%(39/102)和55.9%(57/102)，组间比较，差异均有统计学意义(χ2＝8.212、18.197，P＝0.004、<0.001)。③研究组患儿的PLT、血清Ca2＋、Fib和pH值分别为(344.1±148.7)×109/L，2.36 mmol/L (2.29～2.49 mmol/L)，(492.0±185.1)mg/dL和7.4(7.4～7.5)，均高于对照组的(271.2±147.5)×109/L，2.21 mmol/L (0.08～2.39 mmol/L)，(346.0±165.8)mg/dL和7.4(7.3～7.4)，组间比较，差异均有统计学意义(t＝—2.871，P＝0.005；Z＝－4.002，P＝0.992；t＝－3.639，P<0.001；Z＝－2.108，P＝0.035)。研究组患儿的AST、LDH、DDI和cTnI水平分别为35.0 U/L(25.8～44.2 U/L)，534.5 U/L(471.5～649.5 U/L)，1.1 mg/L(0.5～2.2 mg/L)，0.01 μg/L(0.01～0.01 μg/L)，均低于对照组的46.5 U/L(46.0～87.2 U/L)，673.0 U/L(535.0～1 106.0 U/L)，2.5 mg/L(1.2～4.0 mg/L)和0.01 μg/L(0.01～0.04 μg/L)，组间比较，差异均有统计学意义(Z＝－4.130、3.851、－2.175、－3.716，P均<0.05)。④研究组患儿中，需要呼吸支持治疗、动脉血氧分压(PaO2)/吸入氧气分数(FiO2)<300 mmHg、部分凝血活酶时间(APTT)延长>10 s、PLT<150×109/L、cTnI升高、AST>100 U/L、有神经系统症状者、血清Ca2＋<2.1 mmol/L所占比例，分别为11.8%(6/51)、3.9%(2/51)、8.0%(2/25)、7.8%(4/51)、3.7%(1/27)、6.0%(3/50)、29.4%(15/51)、6.1%(3/49)，均低于对照组的47.1%(48/102)、27.5%(28/102)、35.3%(24/68)、20.6%(21/102)、34.4%(22/64)、25.5%(26/102)、61.8(63/102)和27.6%(27/98)，2组比较，差异均有统计学意义(χ2＝18.545、11.941、6.761、4.040、9.458、8.255、14.241、9.235，P均<0.05)。⑤研究组51例患儿中，49例(96.1%，49/51)尿常规检查结果可见不同数量白细胞及脓细胞，另外2例患儿多次尿常规及尿培养试验均无异常，但是腹部CT检查结果提示肾脓肿。⑥研究组患儿PICU转入率和病死率，均显著低于对照组，并且差异均有统计学意义(χ2＝17.480、6.142，P均<0.05)。

结论

尿源性脓毒症患儿常伴明显白细胞及CRP升高，脏器功能损害较轻，总体预后较好。对伴有明显炎症指标升高，而脏器损害较轻的尿源性脓毒症患儿，可完善清洁中段小便分析，必要时进行尿培养试验及泌尿道超声、CT等检查，对确定感染源有重大意义。

关键词: 脓毒症, 泌尿道感染, 炎症, 细菌感染, 降钙素原, 诊断, 预后, 儿童
Objective

To discuss clinical characteristics of children with urosepsis.

Methods

Between January 2017 and June 2018, a total of 51 children were admitted as study group with the diagnosis of urosepsis. And another 102 children with non-urosepsis were selected into control group through random extraction function of Microsoft Excel 2016. The medical records of demographic data, laboratory tests, and prognosis were collected. Independent-samples t test was performed on platelet count (PLT), fibrinogen (Fib), and erythrocyte sedimentation rate (ESR). White blood cell (WBC), hemoglobin (Hb), alanine transferase (ALT), aspartate aminotransferase (AST), albumin, total bilirubin (TB), lactate dehydrogenase (LDH), creatinine, blood urea nitrogen (BUN), serum Na+ , serum K+ , serum Ca2+ , serum Cl-, glucose, D-dimer (DDI), fibrinogen degradation (FDP), N-terminal pro-brain natriuretic peptide (NTBNP), troponin I (cTnI), pH value, and lactic acid were compared by Mann-Whitney U rank sum test. The chi-square test or continuity correction were used to perform statistical analysis on the ratios of gender ratio, pediatric intensive care unit (PICU) occupancy rate, and mortality. This study was in line with the World Medical Association Declaration of Helsinki revised in 2013. There was no significant difference in gender composition ratio between two groups (χ2=1.593, P=0.207).

Results

①The median age of study group was 6-month old (4-12 months old), which was younger than that of control group [10-month old (5-24 months old)] (Z=-2.660, P=0.008). ② The levels of WBC and CRP in study group were 17.4×109/L [(11.8-26.6)×109/L] and 120 mg/L (87-160 mg/L), which were higher than 12.0×109/L [(5.0-17.6)×109/L] and 48 mg/L (20-135 mg/L) in control group. The differences between two groups were statistically significant (Z=-4.145, -4.465; P all<0.001). The proportion of WBC>15×109/L and CRP>40 mg/L in study group were 62.7% (32/51) and 90.2%(46/51), which were higher than those of control group 38.2%(39/102) and 55.9%(57/102), and the differences between two groups were statistically significant (χ2=8.212, 18.197; P=0.004, <0.001). ③ The values of PLT, Ca2+ , Fib and pH value in study group were (344.1±148.7)×109/L, 2.36 mmol/L (2.29-2.49 mmol/L), (492.0±185.1) mg/dL and 7.4 (7.4-7.5), which were higher than (271.2±147.5)×109/L, 2.21 mmol/L (0.08-2.39 mmol/L), (346.0±165.8) mg/dL and 7.4(7.3-7.4) of control group, and the differences between two groups were statistically significant (t=-2.871, P=0.005; Z=-4.002, P=0.992; t=-3.639, P<0.001; Z=-2.108, P=0.035). While the levels of AST, LDH, DDI and cTnI of study group were 35.0 U/L (25.8-44.2 U/L), 534.5 U/L (471.5-649.5 U/L), 1.1 mg/L (0.5-2.2 mg/L), 0.01 μg/L (0.01-0.01 μg/L), which were lower than 46.5 U/L (46.0-87.2 U/L), 673.0 U/L (535.0-1 106.0 U/L), 2.5 mg/L(1.2-4.0 mg/L) and 0.01 μg/L (0.01-0.04 μg/L) of control group, and the differences between two groups were statistically significant (Z=-4.130, 3.851, -2.175, -3.716; P all<0.05). ④The proportion of children required respiratory support, partial pressure of oxygen in artery(PaO2)/fraction of inspired oxygen(FiO2)<300 mmHg, activated partial thromboplastin time(APTT) prolongation >10 s, PLT<150×109/L, elevated in cTnI, AST>100 U/L, neurological symptoms, Ca2+ <2.1 mmol/L in study group were 11.8% (6/51), 3.9% (2/51), 8.0% (2/25), 7.8% (4/51), 3.7% (1/27), 6.0% (3/50), 29.4% (15/51), 6.1% (3/49), lower than 47.1%(48/102), 27.5%(28/102), 35.3% (24/68), 20.6% (21/102), 34.4% (22/64), 25.5% (26/102), 61.8% (63/102) and 27.6%(27/98) of control group, and the differences were statistically significant (χ2=18.545, 11.941, 6.761, 4.040, 9.458, 8.255, 14.241, 9.235; P all<0.05). ⑤ Among 51 children in study group, 49 children (96.1%, 49/51) showed increased levels of leucocytes and pus cells according to urine routine examination results, another 2 children showed normalities in urine and urine culture but abdominal CT examination results showed renal abscess. ⑥ The PICU transfer rate and mortality of study group were significantly lower than those of control group, and the differences between two groups were statistically significant (χ2=17.480, 6.142; P all<0.05).

Conclusions

Children with urosepsis is more likely to have higher WBC and CRP level, lower organ function rate and better prognosis. For children with sepsis accompanied by high level of inflammatory maker and lower organ dysfunction rate, it is of great significance to carry out early urinalysis, urine culture and have ultrasound or CT of urinary system.

Key words: Sepsis, Urinary tract infections, Inflammasomes, Bacterial infections, Procalcitonin, Diagnosis, Prognosis, Child
表1 2组患儿炎症指标比较
组别 例数 WBC[×109/L，M(P25～P75)] 中性粒细胞百分比(%，±s) CRP[mg/L，M(P25～P75)] PCT[ng/mL，M(P25～P75)]
研究组 51 17.4(11.8～26.6) 61.2±15.8 120(87～160) 6.8(2.0～22.1)a
对照组 102 12.0(5.0～17.6) 58.7±20.5 48(20～135) 4.2(0.6～17.1)a
检验值 ? Z＝－4.145 t＝－0.806 Z＝－4.465 Z＝－1.449
P值 ? <0.001 0.422 <0.001 0.147
组别 例数 WBC>15×109/L[例数(%)] 中性粒细胞百分比>80%[例数(%)] CRP>40 mg/L[例数(%)] PCT>0.5 ng/mL[例数(%)]
研究组 51 32(62.7) 4(7.8) 46(90.2) 34(94.4)a
对照组 102 39(38.2) 19(18.6) 57(55.9) 64(84.2)a
检验值 ? χ2＝8.212 χ2＝3.096 χ2＝18.197 χ2＝1.497
P值 ? 0.004 0.078 <0.001 0.221
表2 2组患儿降钙素原不同升高程度比较
组别 例数 PCT值升高程度[例数(%)]
0～5 ng/mL 5～10 ng/mL 10～15 ng/mL 15～20 ng/mL >20 ng/mL
研究组 36 13(36.1) 8(22.2) 3(8.3) 0(0) 12(33.3)
对照组 76 42(55.3) 10(13.2) 3(3.9) 5(6.6) 16(21.1)
χ2值 ? 7.614
P值 ? 0.087
表3 2组患儿实验室检查结果比较
组别 例数 肝功能
ALT [U/L，M(P25～P75)] AST [ U/L，M(P25～P75)] 白蛋白[g/L，M(P25～P75)] TB [μmol/L，M(P25～P75)] LDH [U/L，M(P25～P75)]
研究组 51 34.0(27.0～44.0) 35.0(25.8～44.2) 37.1(32.2～39.1) 4.1(2.1～7.3) 534.5(471.5～649.5)
对照组 102 36.5(25.0～54.2) 46.5(46.0～87.2) 36.9(31.2～40.9) 4.6(2.3～9.4) 673.0(535.0～1 106.0)
检验值 ? Z＝－1.104 Z＝－4.130 Z＝－0.118 Z＝－0.635 Z＝－3.851
P值 ? 0.269 <0.001 0.906 0.525 <0.001
组别 例数 血常规检查 肾功能
Hb(g/L，±s) PLT(×109/L，±s) 肌酐[μmol/L，M(P25～P75)] BUN [mmol/L，M(P25～P75)])
研究组 51 101.0(89.0～109.0) 344.1±148.7 31.0(26.0～36.5) 3.2(2.2～4.2)
对照组 102 104.5(88.5～115.0) 271.2±147.5 31.5(25.0～40.0) 2.8(2.3～4.3)
检验值 ? Z＝0.681 t＝－2.871 Z＝－0.370 Z＝－0.209
P值 ? 0.497 0.005 0.711 0.835
组别 例数 血糖[mmol/L，M(P25～P75)] 电解质检查
血Na＋ [mmol/L，M(P25～P75)] 血K＋[mmol/L，M(P25～P75)] 血Cl－[mmol/L，M(P25～P75)] 血Ca2＋[mmol/L，M(P25～P75)]
研究组 51 5.5(4.9～6.1) 135.2(133.8～137.8) 4.2(3.7～4.6) 102.9(100.2～105.0) 2.3(2.3～2.5)
对照组 102 5.6(4.9～6.4) 136.0(132.3～138.0) 4.2(3.7～4.5) 102.6(97.9～107.0) 2.2(0.1～2.4)
检验值 ? Z＝－0.601 Z＝－0.266 Z＝－0.452 Z＝－0.010 Z＝－4.002
P值 ? 0.548 0.790 0.652 0.992 <0.001
组别 例数 ESR(mm/h，±s) 凝血功能
Fib(mg/dL，±s) DDI [mg/L，M(P25～P75)] FDP [μg/mL，M(P25～P75)]
研究组 51 48.8±36.4 492.0±185.1 1.1(0.5～2.2) 5.7(3.6～11.6)
对照组 102 42.2±30.0 346.0±165.8 2.5(1.2～4.0) 9.2(4.5～13.7)
检验值 ? t＝－0.608 t＝－3.639 Z＝－2.175 Z＝－0.931
P值 ? 0.547 <0.001 0.030 0.352
组别 例数 NTBNP [pg/mL，M(P25～P75)] cTnI [μg/L，M(P25～P75)] pH值[M(P25～P75)] 乳酸[mmol/L，M(P25～P75)]
研究组 51 1 120.0(373.0～3 180.0) 0.01(0.01～0.01) 7.4(7.4～7.5) 1.8(1.3～2.4)
对照组 102 2 120.0(377.0～7 690.0) 0.01(0.01～0.04) 7.4(7.3～7.4) 1.8(1.1～2.6)
检验值 ? Z＝－1.133 Z＝－3.716 Z＝－2.108 Z＝－0.194
P值 ? 0.257 <0.001 0.035 0.846
表4 2组判断患儿脏器功能损害情况指标的发生率比较[%(n/n′)]
组别 例数 呼吸系统 凝血功能
呼吸支持治疗 PaO2/FiO2<300 mmHg PT延长>3 s APTT延长>10 s Fib<200 mg/L INR>1.5 PLT<150×109/L PLT<100×109/L
研究组 51 11.8(6/51) 3.9(2/51) 4.0(1/25) 8.0(2/25) 12.0(3/25) 4.0(1/25) 7.8(4/51) 3.9(2/51)
对照组 102 47.1(48/102) 27.5(28/102) 19.1(13/68) 35.3(24/68) 22.4(15/67) 13.2(9/68) 20.6(21/102) 13.7(14/102)
χ2值 ? 18.545 11.941 2.192 a 6.761 0.676 a 0.805 a 4.040 3.490
P值 ? <0.001 0.001 0.139 0.009 0.441 0.370 0.044 0.062
组别 例数 心血管系统 消化系统
低血压或者低灌注表现 乳酸>2.5 mmol/L cTnI升高 NTBNP>450 pg/mL 肠鸣音减弱或者消失 AST>100 U/L ALT>80 U/L TB>70 μmol/L
研究组 51 9.8(5/51) 14.3(2/14) 3.7(1/27) 63.6(7/11) 2.0(1/51) 6.0(3/50) 6.0(3/50) 2.0(1/50)
对照组 102 13.7(14/102) 25.0(15/60) 34.4(22/64) 74.5(38/51) 4.9(5/102) 25.5(26/102) 13.7(14/102) 4.9(5/102)
χ2值 ? 0.481 0.255 a 9.458 0.130 —0.195 a 8.255 2.016 －0.176 a
P值 ? 0.448 0.613 0.002 0.718 0.659 0.004 0.156 0.664
组别 例数 神经系统症状b 泌尿系统 电解质
BUN>82 mmol/L 肌酐>10.7 μmol/L 少尿或者无尿 血清Na＋<135 mmol/L 血清K＋<3.5 mmol/L 血K＋>5.5 mmol/L 血清Ca2＋<2.1 mmol/L
研究组 51 29.4(15/51) 4.1(2/49) 4.1(2/49) 3.9(2/51) 38.8(19/49) 18.4(9/49) 4.1(2/49) 6.1(3/49)
对照组 102 61.8(63/102) 4.9(5/102) 4.9(5/102) 2.9(3/102) 47.1(48/102) 20.6(21/102) 4.9(5/102) 27.6(27/98)
χ2值 ? 14.241 0.000 a 0.000 a 0.000 a 0.615 0.103 0.000 a 9.235
P值 ? <0.001 1.000 1.000 1.000 0.443 0.749 1.000 0.002
表5 2组患儿PICU转入率和病死率比较[例数(%)]
组别 例数 转入PICU 死亡
研究组 51 9(17.6) 0(0)
对照组 102 54(52.9) 14(13.7)
χ2值 ? 17.480 6.142
P值 ? <0.001 0.013
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