| Part Ⅰ:The clinical observation of sepsis in pediatric intensive care unitObjectiveThe consistent data about the incidence and outcome of sepsis in pediatric intensive care(PICU) are lacking in China. This study was designed to understand the clinical characteristics of sepsis in Hunan Provincial Children’s Hospital PICU.MethodsThis is a Prospective cohort study performed in Hunan Provincial Children’s Hospital intensive care ward Ⅱ. We prospectively followed the children (from1month to18years old) diagnosis with sepsis from April1,2011to July31,2011, until their discharge,28th day of stay or death。 For all patients we collected the following data at PICU admission:age, gender, pediatric critical illness score (PCIS), associated underlying diseases and cost. Sepsis was diagnosed according to SIRS, sepsis, severe sepsis, and septic shock creteria publiced on Pediatric Critical Care Medicine (PCCM) in2005.ResultsThere were109patients,53.2%sepsis,30.6%severe sepsis and16.2%septic shock. Of these,64.9%were male, and82%from rural areas. The youngest patient was30days, and the oldest was10years old, the median age was294days. And55.9%of the children less than1-year-old. In64.9%, the infection was of respiratory origin followed by intracranial infection. There were66cases were detected with etiology culture:Blood culture was positive in16cases (14.7%), of which nine cases were Gram-negative bacteria, seven cases (45.9%) were Gram-positive bacteria. Sputum culture was positive in59cases (54.1%), Klebsiella pneumoniae (12cases) and Streptococcus pneumoniae (10cases) were the most common. Mortality rate was21.6%. The mortality and the total cost was rising with the severity of sepsis. Compared to the survival group, the average cost of the death group was significantly higher (P=0.005). Multivariate regression analysis showed that the poor prognosis (death) risk factors of severe sepsis include:the PCIS score, procalcitonin, the PO2/FiO2ratio and cystatin C.ConclusionSepsis was very common in yonger children in PICU,and the main cause was respiratory diseases. The mortality and the total cost was rising with the severity of sepsis. Compared to the Survival group, the average cost of the Death group was significantly higher. Multivariate regression analysis showed that poor prognosis (death) risk factors of severe sepsis include:the PCIS score, procalcitonin, the PF ratio and cystatin C. Part II The clinical observation of septic acute kidney injury in pediatric intensive care unitObjectivesWe conducted a study to evaluate the incidence, risk factors and outcomes associated with early acute kidney injury (AKI) in sepsis in PICU.MethodsThe study was a prospectively collected data from the Hunan Provincial Children’s Hospital intensive care ward Ⅱ. We prospectively followed the children (from lmonth to18years old) diagnosis with sepsis from April1,2011to July31,2011, until their discharge,28th day of stay or death. The blood and urine specimens were collected on the1d,3d,7d after the PICU admission. AKI was diagnosed according to Acute Kidney Injury Net(AKIN). We divided the patients into septic AKI group and septic non-AKI group. The main outcome measures were clinical and laboratory data and outcomes.ResultsOf all109patients,17cases could not determine the creatinine change due to the lack of second serum creatinine. Of the92patients, there were32(34.78%) septic AKI patients according to the AKI diagnostic criteria, of which8were AKI stage1,11were stage2and13were stage3. The incidence of AKI induced by sepsis, severe sepsis and septic shock was19.15%(9/47),30%(9/30),93.3%(14/15), respectively. And the mortality of each group were2.12%(1/47),23.3%(7/30),46.7%(7/15), respectively. Sepsis were independent risk factors for AKI occurred, with the severity of sepsis, the incidence increased significantly[OR=4.414(95%confidence interval:1.737-11.216)]. We found that there are significant differences in the prognosis, PICU time, the total cost, the mechanical ventilation, sepsis severity, the PCIS score, the3d serum creatinine, blood urea nitrogen, serum creatine kinase (creatine kinase and its isoenzymes, lactate dehydrogenase), platelets, procalcitonin, bicarbonate and carbon dioxide partial pressure between the two groups. ConclusionThe incidence rate of septic AKI was34.78%in PICU according to the diagnostic criteria of septic AKI. The mortality rate was significantly increased with the severity of sepsis. Compare to the sepsis non-AKI group, septic AKI group had a longer stay in PICU and the total costs increased significantly. There were significant differences in the clinical examination data. Sepsis AKI and other organ damage are closely linked, suggesting that the mechanism of multiple organ dysfunction may be similar. Part Ⅲ The clinical observation of septic acute kidney injury in pediatric intensive care unitObjectivesTo investigate the relationship between the early diagnosis of AKI biomarker (cystatin C, KIM-1, NGAL) and the diagnosis and prognosis of septic AKI.MethodsScreening cases in accordance with the diagnostic criteria for sepsis and acute kidney injury were divided to two group(septic AKI group and septic non-AKI group). Observing the characteristisc of cys C, KIM-1and NGAL in the diagnosis and the prognosis of septic AKI. Study the diagnostic capabilities and the prediction ability of each indicators.ResultWe found that the concentration of Cys C, KIM-1, NGAL was increased sinificantly at the time of PICU admission. Compare to serum crearinine, they were earlier diagnostic indicators and prognostic marker of septic AKI. The area under the curve(AUC) for reciver operationg characteristic(ROC) for Cys C-2h for prediction of septic AKI was0.927, the cutoff was1.045mg/1, The sensitivites and specificities were86.5%,93.8%, respectively. The AUC for prognosis of septic AKI was0.815. The cutoff was2.805mg/1, and the sensitivity and specificitiy were80%and83.1%, respectively. The AUC for uKIM-1for prediction of septic AKI was0.852, the cutoff was20.47ng/1, The sensitivity and specificitiy were90.7%and72.5%, respectively. The AUC for prognosis of septic AKI was0.799(95%CI:0.687-0.910, P<0.001). The cutoff was33.4ng/l, sensitivity and specificitiy were76.9%and72.9%, respectively. The AUC for pNGAL for prediction of septic AKI was0.931, the cutoff was63.61pg/ml, The sensitivity and specificitiy were87.5%and86.6%, respectively. The AUC for prognosis of septic AKI was0.815, the cutoff was134.61pg/ml, sensitivity and specificity were85.7%and66.2%, respectively. The AUC for uNGAL for prediction of septic AKI was0.906, the cutoff was65.88pg/ml. The sensitivity and specificity were74.2%and96.8%, respectively. The AUC for prognosis of septic AKI was0.808, the cutoff was80.37pg/ml, sensitivity and specificity were83.3%and86%, respectively. All of them were positively correlated with the peak serum creatinine concentration(r=0.330-0.585, P<0.05).ConclusionSeptic AKI in pediatric intensive care unit have higher incidence rate; cys C、uKIM-1、pNGAL、uNGAL were earlier marker for diagnose and predict AKI。All of them were positively correlated with the peak serum creatinine concentration。... |
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