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

doi:10.3877/cma.j.issn.1673-5250.2023.02.009

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(%)]
组别	例数	男	女	年龄[岁，M (Q₁，Q₃)]	≤1岁	1~5岁	≥5岁	先天性心脏病	早产儿	肿瘤	使用血管活性药物[例数(%)]
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(%)]
组别	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(%)]
组别	例数	男	女	年龄[岁，M (Q₁，Q₃)]	≤1岁	1~5岁	≥5岁	先天性心脏病	早产儿	肿瘤	使用血管活性药物[例数(%)]
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(%)]
组别	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
指标	AUC	AUC 95%CI	P值	灵敏度(%)	特异度(%)	最佳临界值
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	—

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
指标	AUC	AUC 95%CI	P值	灵敏度(%)	特异度(%)	最佳临界值
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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