Guiding effect of lactic acid clearance rate detection after early goal-directed therapy on timing selection of continuous blood purification for septic shock in children

doi:10.3877/cma.j.issn.1673-5250.2020.05.007

Objective

To explore guiding effect of lactic acid clearance rate detection of children with septic shock (SS) after receiving early goal-directed therapy (EGDT) on timing selection of further receiving continuous blood purification (CBP).

Methods

From January 2017 to December 2019, a total of 36 children with SS admitted to pediatric intensive care unit (PICU) in Maternity and Child Health Care Hospital of Guangxi Zhuang Autonomous Region were selected as research subjects, with lactic acid clearance rate<10% after receiving EGDT and meeting the inclusion and exclusion criteria of this study. The children with SS were randomly divided into study group (n=21) and control group (n=15) by envelope method. They were treated with early CBP, or first treated with cluster therapy, and then treated with CBP if their organ functions showed progressive deterioration, respectively. General clinical data, plasma levels of interleukin (IL)-6, 10 and tumor necrosis factor (TNF)-α on admission (d0), 3 days after admission (d3), and 5 days after admission (d5), and duration of plasma lactic acid concentration up to standard level, duration of urine volume up to standard level, CBP treatment time, mechanical ventilation time, and hospital stay in PICU of two groups were collected. ANOVA of repeated measurement data and independent-samples t test were used for statistical comparisons. There were no statistical differences between two groups in general clinical data, such as composition ratios of gender, age and primary infection locations, plasma lactic acid concentration before treatment, and pediatric critical illness score (PCIS) (P>0.05). The procedure followed in this study conformed to the standards of medical ethics in Maternity and Child Health Care Hospital of Guangxi Zhuang Autonomous Region and has been approved by this ethics committee [approval No. (2017-1)4-16]. All guardians of children have signed informed consent of clinical research.

Results

①ANOVA of repeated measurement data results of plasma IL-6, IL-10 and TNF-α levels on d0, d3 and d3 showed that as for plasma levels of IL-6 and IL-10, the interaction between different treatment measures and time factors was statistically significant (F_{treatment×time}=14.937, P<0.001; F_{treatment×time}=5.314, P<0.001), while as for plasma level of TNF-α, the interaction between different treatment measures and time factors was not statistically significant (F_{treatment×time}=2.918, P=0.092). Results of further analysis by fixing time factor showed that plasma levels of IL-6, IL-10 and TNF-α on d3 in study group were significantly lower than those in control group, and all differences were statistically significant (t=-4.957, P<0.001; t=-6.545, P<0.001; t=-2.638, P=0.012). Results of further analysis by fixing factor of treatment measures showed that plasma levels of IL-6, IL-10 and TNF-α in study group and control group showed a progressive decrease trend, and there were statistical differences in further comparisons between different times within each group (P<0.05) except for the comparison of d3 and d5 plasma levels of TNF-α in study group. ②Duration of plasma lactic acid concentration up to standard level, duration of urine volume up to standard level, CBP treatment time, mechanical ventilation time, and hospital stay in PICU of children in study group were (4.7±1.2) d, (4.3±1.5) d, (3.4±1.2) d, (7.1±1.7) d, (10.1±2.4) d, respectively, which were significantly shorter than those in control group (6.3±1.4) d, (5.4±1.3) d, (4.3±1.1) d, (8.4±1.8) d, (12.8±2.5) d, and all differences were statistically significant (t=3.648, 2.192, 2.397, 2.173, 3.294, P=0.001, 0.035, 0.022, 0.037, 0.002).

Conclusions

Early CBP treatment for SS children with lactic acid clearance rate<10% after receiving EGDT can rapidly reduce intensity of inflammatory response, control the disease, and shorten course of disease. Due to relatively small sample size included in this study, guiding effect of lactic acid clearance rate after receiving EGDT on timing selection of CBP for children with SS still needs to be further confirmed by multi-center, large-sample, randomized controlled trials.

Key words: Shock, septic, Hemodiafiltration, Lactic acid, Interleukin-6, Interleukin-10, Tumor necrosis factor-alpha, Early goal-directed therapy, Lactic acid clearance rate, Continuous blood purification, Child

表1 2组脓毒性休克患儿临床资料比较

组别	例数	性别[例数(%)]		年龄[例数(%)]			治疗前血浆乳酸浓度(mmol/L，±s)
组别	例数	男	女	<1岁	1～3岁	>3岁	治疗前血浆乳酸浓度(mmol/L，±s)
研究组	21	12(57.1)	9(42.9)	9(42.9)	6(28.6)	6(28.6)	5.4±1.6
对照组	15	8(53.3)	7(46.7)	7(46.7)	5(33.3)	3(20.0)	5.1±2.1
检验值		χ²＝0.051		χ²＝0.351			t＝0.488
P值		0.821		0.839			0.629
组别	例数	原发感染部位[例数(%)]					治疗前PCIS(分，±s)
组别	例数	肺部	肠道及腹腔	血流	中枢神经系统	其他部位	治疗前PCIS(分，±s)
研究组	21	6(28.6)	5(23.8)	5(23.8)	2(9.5)	3(14.3)	66.4±7.2
对照组	15	5(33.3)	3(20.0)	4(26.7)	2(13.3)	1(6.7)	69.5±7.3
检验值		χ²＝0.722					t＝-1.278
P值		0.949					0.210

表1 2组脓毒性休克患儿临床资料比较

组别	例数	性别[例数(%)]		年龄[例数(%)]			治疗前血浆乳酸浓度(mmol/L，±s)
组别	例数	男	女	<1岁	1～3岁	>3岁	治疗前血浆乳酸浓度(mmol/L，±s)
研究组	21	12(57.1)	9(42.9)	9(42.9)	6(28.6)	6(28.6)	5.4±1.6
对照组	15	8(53.3)	7(46.7)	7(46.7)	5(33.3)	3(20.0)	5.1±2.1
检验值		χ²＝0.051		χ²＝0.351			t＝0.488
P值		0.821		0.839			0.629
组别	例数	原发感染部位[例数(%)]					治疗前PCIS(分，±s)
组别	例数	肺部	肠道及腹腔	血流	中枢神经系统	其他部位	治疗前PCIS(分，±s)
研究组	21	6(28.6)	5(23.8)	5(23.8)	2(9.5)	3(14.3)	66.4±7.2
对照组	15	5(33.3)	3(20.0)	4(26.7)	2(13.3)	1(6.7)	69.5±7.3
检验值		χ²＝0.722					t＝-1.278
P值		0.949					0.210

表2 2组脓毒性休克患儿不同时间炎症指标比较(pg/mL，±s)

组别	例数	血浆IL-6水平			血浆IL-10水平			血浆TNF-α水平
组别	例数	d0	d3	d5	d0	d3	d5	d0	d3	d5
研究组	21	425±141	134±56	69±27	151±58	25±11	17±8	54±17	16±7	16±9
对照组	15	412±165	284±107	83±44	140±54	54±15	19±11	60±22	24±11	15±8
F_{处理×时间}值		14.937			5.314			2.918
P值		<0.001			0.027			0.092
F_处理值		3.042			0.571			1.294
P值		0.090			0.454			0.264
F_时间值		232.365			233.391			283.812
P值		<0.001			<0.001			<0.001

表2 2组脓毒性休克患儿不同时间炎症指标比较(pg/mL，±s)

组别	例数	血浆IL-6水平			血浆IL-10水平			血浆TNF-α水平
组别	例数	d0	d3	d5	d0	d3	d5	d0	d3	d5
研究组	21	425±141	134±56	69±27	151±58	25±11	17±8	54±17	16±7	16±9
对照组	15	412±165	284±107	83±44	140±54	54±15	19±11	60±22	24±11	15±8
F_{处理×时间}值		14.937			5.314			2.918
P值		<0.001			0.027			0.092
F_处理值		3.042			0.571			1.294
P值		0.090			0.454			0.264
F_时间值		232.365			233.391			283.812
P值		<0.001			<0.001			<0.001

表3 2组脓毒性休克患儿预后相关指标比较(d，±s)

组别	例数	血浆乳酸浓度达标时间	尿量达标时间	CBP治疗时间	机械通气时间	PICU住院时间
研究组	21	4.7±1.2	4.3±1.5	3.4±1.2	7.1±1.7	10.1±2.4
对照组	15	6.3±1.4	5.4±1.3	4.3±1.1	8.4±1.8	12.8±2.5
t值		3.648	2.192	2.397	2.173	3.294
P值		0.001	0.035	0.022	0.037	0.002

表3 2组脓毒性休克患儿预后相关指标比较(d，±s)

组别	例数	血浆乳酸浓度达标时间	尿量达标时间	CBP治疗时间	机械通气时间	PICU住院时间
研究组	21	4.7±1.2	4.3±1.5	3.4±1.2	7.1±1.7	10.1±2.4
对照组	15	6.3±1.4	5.4±1.3	4.3±1.1	8.4±1.8	12.8±2.5
t值		3.648	2.192	2.397	2.173	3.294
P值		0.001	0.035	0.022	0.037	0.002

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