Investigation Of Continuous Blood Purification Therapeutic Indications And Mechanism In Children With Severe Sepsis

BackgroudsPediatric sepsis, a thornic problem in critically ill children, is the primary cause of death among children. Continuous blood purification technology (CBP) is much effective in treatment of pediatric sepsis and generally applied in pediatric sepsis. By far, there is not enough comprehension in treatment mechanism of CBP treatment in pediatric sepsis. It is essential to investigate the mechanism. The change of typical biomarkers in treatment mechanism of CBP treatment in pediatric sepsis has not been investigated by scientifically controlled studies. In the research, we investigated the curative effect, the therapeutic indications and juncture of CBP treatment in pediatric sepsis, the feasibility of 39 human cartilage glycoprotein-39 (YKL-40) and C-reactive protein (CRP) as typical biomarkers in treatment mechanism of CBP applied in pediatric sepsis.ObjectivesIn the study, we report the curative effect, the therapeutic indications and juncture of CBP treatment in pediatric sepsis, the disease severity of ill children, the changes of inflammatory factors, YKL-40 and CRP concentration in peripheral blood when treated pediatric sepsis with CBP. Then made correlation analysis between YKL-40 concentration to IL-6, TNF-a concentration and disease severity scores, CRP concentration to IL-6, TNF-a concentration and disease severity scores. By the study, we investigated the relationship with prognosis and YKL-40 and CRP as typical biomarkers in treatment mechanism of CBP treatment in pediatric sepsis, offered treatment basis for clinical evaluation of CBP.Part oneMethods25 cases of pediatric sepsis children were collected from Byi Children's Hospital, Beijing Command Hospital People Liberation Army from August 2008 to August 2010, all ill children were selected in line with the 2005 Meeting of the International Sepsis published diagnostic criteria for severe sepsis in children, healthy children to the same period illness children as control group. All illness children received routine comprehensive treatment with primary disease treatment, antibiotic treatment, nutrition treatment, support treatment and liquid, electrolyte acid-alkali balancing before CBP treatment. All 25 cases of illness children required assist respiration with mechanical ventilation,15 cases needed maintain with dopamine and noradrenaline.(1)Blood samples were collected from radial artery at four points of CBP treatment 0 hours,12 hours,24 hours,48 hours respectively. Each volume 5 mL blood samples were made blood serum with centrifugating in low temperature, then were cryopreserved. Each volume 2 mL blood samples were taken for conventional biochemical tests of the renal function, liver function, blood electrolyte and blood lactate at different time points. At the same time, arterial blood gas analysis was done at different time points. Score changes, in cases of pediatric critical illness before and after CBP, was calculated according with the pediatric critical illness score published by the subspecialty group of emergency medicine, society of pediatrics, Chinese medical association, was used to predict the ill children death risk.(2)A euzymelinked immunosorbent assay was used to determine inflammation mediators of IL-6 and TNF-a concentration at different time points.Results(1) Evaluation of clinical outcome was done in 25 cases of illness children with 48 hours of CBP treatment. Clinical symptoms improved in 18 cases, deteriorated and resulted in death in 5 cases, treatment were given up in two case,72% cure rate.①The mean arterial blood pressure in the four time points (the beginning if treatment,12 hour,24 hour and 48 hour) were 42±12.6 mmHg,54±9.6 mmHg, 55±7.9 mmHg,58±5.9 mmHg. The mean arterial blood pressure increased significantly (P<0.05) before and after CBP treatment. The dosages of dopamine in the four time points were 17.05±3.26μg/kg·min,14.19±4.95μg/kg·min, 8.60±6.51μg/kg·min,4.25±3.12μg/kg·min. The dosages of dopamine decreased significantly (P<0.05) before and after CBP treatment 12 hour. The dosages of noradrenaline were 1.41±0.39μg/kg·min,0.62±0.30μg/kg.min, 0.08±0.03μg/kg·min,0.03±0.02μg/kg·min. The dosages of noradrenaline decreased significantly (P<0.05) before and after CBP treatment 12 hour. The urine amount for illness children in the four time points were 0.85±0.54 mL/kg·h,0.86±0.55 mL/kg·h, 0.89±0.56 mL/kg. h,1.35±0.686 mL/kg. h. The difference was significant (P<0.05) compared at the beginning of treatment and 48 hour after treatment.②The level of blood serum creatinine in the four time points were 361.95±70.26μmol/L,279.69±61.56μmol/L,189.64±50.36μmol/L,103.21±33.45μmol /L. The difference was significant (P<0.05) compared at the beginning of treatment and 12 hour after CBP treatment. The difference was very significant (P<0.01) compared at the beginning of treatment and 24hour and 48hour after CBP treatment. The level of urea nitrogen in the four time points were 39.21±10.24 mmol/L, 23.2±7.7mmol/L,14.76±2.12mmol/L,7.78±1.63mmol/L. The difference was significant (P<0.05) compared at the beginning of treatment and 12 hour after CBP treatment. The difference was very significant (P<0.01) compared at the beginning of treatment and 24hour and 48hour after CBP treatment.③The blood gas PH level in the four time points were 7.14±0.22,7.33±0.12, 7.4±0.16,7.33±0.11. PH level increased significantly (P<0.05). The BE blood gas value in the four time points were-19.58±6.45,-8.21±2.73,-4.56±1.78,-0.61±1.75. BE value increased very significantly (P<0.01) compared at the beginning of treatment and CBP treatment. The oxygenation index (PO2/FiO2) in the four time points were 188.76±85.61,245.32±82.56,301.24±78.35,352.42±81.56. The difference was significant (P<0.05) compared at the beginning of treatment and 12 hour after CBP treatment. The difference was very significant (P<0.01) compared at the beginning of treatment and 24hour and 48hour after CBP treatment.④Severity scores of illness cases increased significantly (P<0.05) before and after CBP treatment 48 hour.(2) IL-6 concentration in the four time points were 705.21±87.62 ng/L, 324.31±86.34 ng/L,213.64±62.35 ng/L,164.35±51.23ng/L. IL-6 concentration decreased significantly (P<0.05) before and after CBP treatment 12 hour. IL-6 concentration was significant (P<0.05) compared at the beginning of treatment and CBP treatment 24 hour and 48 hour. TNF-a concentration in the four time points were 987.52±91.25ng/L,871.36±97.56 ng/L,541.23±111.25 ng/L,437.69±107.19 ng/L. TNF-a concentration was significant (P<0.05) compared at the beginning of treatment and CBP treatment 12 hour. TNF-a concentration was very significant (P<0.01) compared at the beginning of treatment and CBP treatment 24 hour and 48 hour.(3) There were 8 cases liver failure in pediatric sepsis children. The total bilirubin concentration was 258.98±117.38 U/L and 93.51±28.34 U/L at the beginning of treatment and CBP treatment 12 hour. Blood ammonia concentration was 189.31±46.23μg/dL and 56.26±10.16μg/dL, glutamate-pyruvate transaminase (GPT) was 1281.19±363.18 U/L and 390.58±169.12 U/L, glutamic oxaloacetic transaminase(GOT) was 1018.71±72.24 U/L and 300.77±141.46 U/L, prothrombin activity(PTA) was 28.22±6.76% and 61.46±13.75%.There were all have very significant (P<0.01) compared at the beginning of treatment and CBP treatment12 hour.(4) The cure rate of CBP treatment in pediatric sepsis maybe obiously increasing when we made best CBP treatment therapeutic indications, juncture and method.Part twoMethods(1) A euzymelinked immunosorbent assay was used to determine YKL-40 concentration blood serum and immunoturbidimetry assay to determine CRP concentration. The blood serum of YKL-40 and CRP concentration were calculated by regression equation made by standard curve of YKL-40 and CRP concentration. (2) YKL-40 mRNA expression in pediatric sepsis illness blood was determined by RT-PCR.(3) Peripheral blood monouclear cells (PBMC) in pediatric sepsis illness blood was obtained and then cultivated. The flow cytometry (FCM) was used to detect CD 14 and CD 16. The YKL-40 allocated expression in pediatric sepsis illness blood was detected by immunohistochemistry (IHC).Results(1) YKL-40 concentration of pediatric sepsis illness blood in the four time points were180.56±23.25μg/L,100.21±21.32μg/L,80.35±35.26μg/L, 60.53±26.21μg/L. YKL-40 concentration decreased significantly (P<0.05) before and after CBP treatment 12 hour. IL-6 concentration was very significant (P<0.01) compared at the beginning of treatment and CBP treatment. CRP concentration of pediatric sepsis illness blood in the four time points were 662.23±69.56μg/L, 620.21±58.32μg/L,200.32±42.36μg/L,120.56±29.21μg/L. CRP concentration was significant (P<0.05) compared at the beginning of treatment and CBP treatment 12 hour, was very significant (P<0.01) compared at the beginning of treatment and CBP treatment 24 hour and 48 hour.(2) The YKL-40 mRNA of pediatric sepsis illness blood relative expression in the four time points were 1 (0.6-1.7),0.5 (0.4-0.6),0.5 (0.3-0.7),0.4 (0.2-0.6) CRP concentration was significant (P<0.05) compared at the beginning of treatment and CBP treatment 12 hour, was very significant (P<0.01) compared at the beginning of treatment and CBP treatment 24 hour and 48 hour. The YKL-40 mRNA relative expression was significant (P<0.05) compared at the beginning of treatment and CBP treatment 12 hour and 24 hour, was very significant (P<0.01) compared at the beginning of treatment and CBP treatment 48 hour.(3) The YKL-40 protein was expressed in CD16+ monocytes with a dim expression of CD14. The FCM showed that the CD16 expression in the four time points were 35.2±5.930%,26.3±5.21%,27.8±6.92%,23.8±5.12%, the expression was decreased. The YKL-40 expression in histoleucocyte was positive by IHC. (4) The YKL-40 concentration, CRP concentration and CD 16 expression of 5 pediatric sepsis death cases blood in the four time points were higher the live pediatric sepsis illness, there were very significant (P<0.01)Part threeMethodsTo make correlation analysis with Bivariate Correlation between YKL-40 concentration with IL-6, TNF-a concentration and disease severity scores, CRP concentration with IL-6, TNF-a concentration and disease severity scores.ResultsThere were positive correlation between YKL-40 concentration with IL-6, TNF-a concentration and disease severity scores, CRP concentration with IL-6, TNF-a concentration and disease severity scores.Conclusions1 CBP can improve the treatment of pediatric sepsis, reduce the death rate of the treatment, was effective in the treatment by improving oxygenation improvement, correcting metabolic acidosis, increasing the tissue perfusion, stabilizing blood pressure and educing boosting pressure drugs usage.2 The cure rate of CBP treatment in pediatric sepsis maybe obiously increasing when we made best CBP treatment therapeutic indications, juncture and method.3 CBP is an effective treatment method for pediatric sepsis. It effectively removes blood cytokines which may be the possible mechanisms for the CBP treatment of pediatric sepsis.4 YKL-40 and CRP may be as biomarkers to evaluate CBP treatment for pediatric sepsis. There are bad prognosis if the YKL-40,CRP concentration and CD16 expression keep in higher level.