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中华妇幼临床医学杂志(电子版) ›› 2023, Vol. 19 ›› Issue (02) : 178 -186. doi: 10.3877/cma.j.issn.1673-5250.2023.02.009

论著

儿童重症监护室脓毒症患儿死亡相关影响因素分析
刘顺利, 田志青, 曹杨, 乔莉娜†()   
  1. 四川大学华西第二医院儿科、出生缺陷与相关妇儿疾病教育部重点实验室、国家卫生健康委员会时间生物学重点实验室(四川大学)，成都　610041
  • 收稿日期:2022-10-15 修回日期:2023-02-10 出版日期:2023-04-01
  • 通信作者: 乔莉娜

Analysis of death-related factors in children with sepsis among Pediatric Intensive Care Unit

Shunli Liu, Zhiqing Tian, Yang Cao, Lina Qiao†()   

  1. Department of Pediatric Intensive Care Unit, Key Laboratory of Birth Defectsand Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, NHC Key Laboratory of Chronobiology (Sichuan University), Chengdu 610041, Sichuan Province, China
  • Received:2022-10-15 Revised:2023-02-10 Published:2023-04-01
  • Corresponding author: Lina Qiao
  • Supported by:
    National Key R & D Plan Project(2021YFC2701705); Developmental Special Project of Sichuan Provincial Central Leading Local Science and Technology(2021ZYD0105)
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引用本文：

刘顺利, 田志青, 曹杨, 乔莉娜. 儿童重症监护室脓毒症患儿死亡相关影响因素分析[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(02): 178-186.

Shunli Liu, Zhiqing Tian, Yang Cao, Lina Qiao. Analysis of death-related factors in children with sepsis among Pediatric Intensive Care Unit[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2023, 19(02): 178-186.

目的

探讨儿童重症监护病房(PICU)脓毒症患儿死亡相关影响因素。

方法

选择2019年6月至2021年1月，于四川大学华西第二医院PICU收治的234例脓毒症患儿为研究对象。采用回顾性分析方法，按照PICU治疗结局，将其分别纳入死亡组(n＝44)和存活组(n＝190)。对2组患儿临床病例资料、入院24 h内实验室检查结果进行统计学分析。结合已有研究结果及临床经验及单因素分析中差异有统计学意义(P<0.05)因素，对脓毒症患儿死亡相关影响因素进行多因素非条件logistics回归分析，并建立logistic回归方程(预测模型)。绘制不同指标预测脓毒症患儿死亡相关影响因素的受试者工作特征(ROC)曲线，并计算曲线下面积(AUC)。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》的要求。

结果

①2组患儿年龄、脓毒症不同严重程度构成比、使用血管活性药物者占比比较，差异均有统计学意义(P<0.05)；年龄<5岁和≥5岁患儿的脓毒症严重程度占比比较，差异均有统计学意义(P<0.05)。②2组患儿的血清血小板计数(PLT)、丙氨酸转移酶(ALT)、尿素氮、血清肌酐(SCr)、凝血酶原时间(PT)、血清HCO3－、血清乳酸浓度比较，差异均有统计学意义(P<0.05)。③2组患儿的Glasgow评分、儿童序贯器官衰竭评分(pSOFA)和第3代小儿死亡危险(PRISMⅢ)评分比较，差异均有统计学意义(P<0.05)，而2组患儿小儿危重病例评分(PCIS)比较，差异无统计学意义(P>0.05)。④多因素非条件logistics回归分析显示，年龄(OR＝1.011，95%CI：1.005~1.018，P<0.001)、血清乳酸浓度(OR＝1.132，95%CI：1.005~1.275，P＝0.041)是导致脓毒症患儿死亡的独立危险因素。建立的预测脓毒症患儿死亡相关影响因素的logistic回归方程为：y＝0.918－0.312x1+0.124x2+0.011x3(x1为Glasgow评分，x2为血清乳酸浓度，x3为年龄)，对脓毒症患儿死亡具有良好预测价值，其ROC-AUC为0.84(95%CI：0.775~0.904，P<0.05)，预测脓毒症患儿死亡的灵敏度为86.4%，特异度为68.4%。

结论

该logistic回归方程对预测脓毒症患儿预后相关影响因素的灵敏度及综合价值，均优于pSOFA和PRISMⅢ，适用于对脓毒症患儿预后不良的早期筛查。

关键词: 脓毒症, 死亡, 预后, 血清乳酸, 年龄因素, Glasgow评分, Logistic模型, 儿童
Objective

To investigate the death-related factors in children with sepsis among Pediatric Intensive Care Unit (PICU).

Methods

From June 2019 to January 2021, 234 children with sepsis admitted to PICU of West China Second University Hospital, Sichuan University were selected in this study. They were divided into death group (n=44) and survival group (n=190) based on whether they died during PICU stay. Clinical data and laboratory test results within 24 hours of admission were retrospectively analyzed. Based on factors with statistically significant differences (P<0.05) in the univariate analysis and clinical experience, multivariate unconditional logistic regression analysis was conducted to identify the death-related factors of children with sepsis, and a logistic regression equation (predictive model) was established. Receiver operating characteristic (ROC) curves were used to evaluate the predictive value of different indicators for mortality risk in children with sepsis, and the area under the curve (AUC) was calculated. The procedures followed in this study was in line with the World Medical Association Declaration of Helsinki revised in 2013.

Results

① There were statistically significant differences in the age, severity of sepsis, and proportion of patients using vasoactive drugs between two groups (P<0.05). There were also statistically significant differences in the proportion of patients with different levels of sepsis severity between patients aged <5 years and those aged ≥5 years (P<0.05). ② There were statistically significant differences in the levels of serum platelet count (PLT), alanine transaminase (ALT), blood urea nitrogen, serum creatinine (SCr), prothrombin time (PT), serum HCO3-, and lactate between two groups (P<0.05). ③ There were statistically significant differences in the Glasgow score, pediatric sequential organ failure assessment (pSOFA), and pediatric risk of mortality Ⅲ(PRISM Ⅲ) scores between two groups (P<0.05), but no statistically significant difference in the pediatric critical illness score (PCIS) score (P>0.05). ④Multivariate unconditional logistic regression analysis showed that age (OR=1.011, 95%CI: 1.005-1.018, P<0.001) and lactate level (OR=1.132, 95%CI: 1.005-1.275, P=0.041) were independent risk factors for prognosis of children with sepsis. The logistic regression equation (y=0.918-0.312x1+ 0.124x2+ 0.011x3, where x1 is the Glasgow score, x2 is the lactate level, and x3 is age) had good predictive value for mortality risk in children with sepsis, with the ROC-AUC of 0.84 (95%CI: 0.775-0.904, P<0.05). Its sensitivity was 86.4%, and its specificity was 68.4%.

Conclusions

The logistic regression equation established in this study has higher sensitivity and comprehensive value in predicting mortality risk in children with sepsis than the pSOFA score and PRISMⅢ score, and are suitable for early screening of poor prognosis in children with sepsis.

Key words: Sepsis, Death, Prognosis, Lactic acid, Age factors, Glasgow score, Logistic models, Child
表1 不同年龄段脓毒症患儿严重程度比较[例数(%)]
不同年龄段 例数 脓毒症 严重脓毒症 脓毒性休克
<5岁 175 35(20.0) 89(50.9) 51(29.1)
≥5岁 59 4(6.8) 38(64.4) 17(28.8)
χ2值   6.12  
P值   0.047  
表2 2组脓毒症患儿一般临床资料比较
组别 例数 性别[例数(%)] 年龄[岁，M (Q1，Q3)] 年龄段[例数(%)] 基础疾病[例数(%)] 使用血管活性药物[例数(%)]
男 女 ≤1岁 1~5岁 ≥5岁 先天性心脏病 早产儿 肿瘤
存活组 190 109(57.4) 81(42.6) 8.0(2.0，22.0) 114(60.0) 33(17.4) 43(22.6) 13(6.8) 24(12.6) 5(2.6) 31(16.3)
死亡组 44 29(68.9) 15(34.1) 16.0(8.2，143.8) 20(45.4) 8(18.2) 16(36.4) 1(2.3) 0(0) 5(11.4) 25(56.8)
统计值   χ2＝0.87 Z＝2.96 χ2＝4.01 χ2＝6.39 χ2＝32.19
P值   0.224 0.003 0.137 0.076 <0.001
组别 例数 脓毒症严重程度[例数(%)] 感染部位[例数(%)] 血培养[例数(%)]
脓毒症 严重脓毒症 脓毒性休克 肺 腹腔 颅内 血液 其他部位 阳性 阴性
存活组 190 37(19.5) 113(59.5) 40(21.0) 82(42.1) 32(16.8) 40(21.0) 23(12.1) 13(6.8) 23(12.1) 167(87.9)
死亡组 44 2(4.5) 14(31.8) 28(63.6) 18(40.9) 4(9.1) 17(38.5) 4(9.1) 1(2.3) 4(9.1) 40(90.9)
统计值   χ2＝32.11 χ2＝7.50 χ2＝0.32
P值   <0.001 0.109 0.397
表3 2组脓毒症患儿PICU治疗24 h内实验室检查指标比较[M(Q1，Q3)]
组别 例数 MAP(mmHg) WBC(×109/L) NLR Hb(g/L) PLT(×109/L) CRP(mg/L)
存活组 190 68.7(60.3，77.2) 10.5(6.0，15.9) 1.6(0.7，3.5) 94.0(77.0，110.0) 286.5(180.5，392.3) 27.2(4.9，96.6)
死亡组 44 64.8(53.5，77.3) 9.5(6.4，14.6) 2.5(0.9，6.0) 98.5(82.5，106.5) 196.5(47.5，352.5) 30.7(4.9，115.9)
Z值   －1.36 －0.51 －1.60 －0.28 －2.47 －0.73
P值   0.175 0.612 0.109 0.777 0.014 0.468
组别 例数 ALT(U/L) TB(mmol/L) 尿素氮(mmol/L) SCr(μmol/L) PT(s) APTT(s)
存活组 190 32.0(22.2，54.5) 12.7(6.8，21.7) 4.3(2.8，7.4) 24.0(18.0，47.5) 13.6(12.2，15.5) 31.6(27.2，37.3)
死亡组 44 50.5(24.8，119.0) 9.3(5.0，26.8) 5.2(4.1，8.9) 35.5(26.8，52.8) 14.2(13.4，18.9) 33.7(27.5，46.6)
Z值   －2.31 －0.59 －3.95 －4.08 －3.49 －1.45
P值   0.021 0.555 <0.001 <0.001 <0.001 0.148
组别 例数 pH值 血糖(mmol/L) 血清HCO3－(mmol/L) 血清乳酸(mmol/L) PCT(ng/mL) 氧合指数
存活组 190 7.4(7.4，7.5) 5.8(4.9，7.0) 21.0(17.2，24.3) 1.6(1.0，2.9) 1.6(0.3，11.6) 312.6(213.9，421.3)
死亡组 44 7.4(7.3，7.5) 6.4(4.9，8.2) 18.0(13.5，23.4) 2.3(1.6，4.9) 3.0(0.5，22.0) 274.9(168.9，4340.0)
Z值   －1.21 －1.05 －2.42 －3.06 －1.38 －1.35
P值   0.228 0.294 0.016 0.002 0.166 0.178
表4 2组脓毒症患儿危重程度评分比较[分，M(Q1，Q3)]
组别 例数 Glasgow评分 pSOFA评分 PRISMⅢ评分 PCIS评分
存活组 190 13.00(10.25，14.00) 4.00(3.00，7.00) 4.00(0，8.00) 76.00(71.00，80.00)
死亡组 44 7.50(3.00，11.25) 5.50(3.75，9.75) 10.00(5.00，17.50) 76.00(68.00，82.00)
Z值   －5.47 －2.94 －5.31 －1.79
P值   <0.001 0.003 <0.001 0.073
表5 脓毒症患儿预后相关影响因素的多因素非条件logistics回归分析
影响因素 B BE Wald值 P值 OR值 OR值95%CI
Glasgow评分 －0.312 0.055 32.345 <0.001 0.732 0.657~0.815
血清乳酸 0.124 0.061 4.157 0.041 1.132 1.005~1.275
年龄 0.011 0.003 12.931 <0.001 1.011 1.005~1.018
常数项 0.981 0.616 2.532 0.112 2.667 —
表6 预测脓毒症患儿预后相关影响因素的ROC曲线分析结果
指标 ROC曲线 灵敏度(%) 特异度(%) 最佳临界值
AUC AUC 95%CI P值
Glasgow评分a 0.760 0.670~0.850 <0.001 65.9 80.5 11分
PCIS评分a 0.588 0.480~0.695 0.069 45.5 77.9 71分
pSOFA评分 0.641 0.549~0.734 0.004 45.4 74.2 7分
PRISMⅢ评分 0.756 0.674~0.838 <0.001 59.1 81.6 10分
血清乳酸 0.648 0.558~0.739 0.002 84.1 46.8 1.5 mmol/L
logistic回归方程(预测模型)b 0.840 0.775~0.904 <0.001 86.4 68.4 —
图1 预测脓毒症患儿死亡风险增高的ROC曲线图注：a本研究建立的预测脓毒症患儿死亡相关影响因素的logistic回归方程(预测模型)为y＝0.918－0.312x1+0.124x2+0.011x3，其中，x1为Glasgow评分，x2为血清乳酸浓度，x3为年龄。ROC为受试者特征曲线。PRISMⅢ评分为第3代小儿死亡危险评分，pSOFA儿童序贯器官衰竭评分，PCIS为小儿危重病例评分
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