中重度婴幼儿急性呼吸窘迫综合征死亡风险因素分析  

Analysis of risk factors of mortality in infants and toddlers with moderate to severe pediatric acute respiratory distress syndrome

作　　者：方伯梁[1] 许峰[2] 陆国平 任晓旭[4] 张育才 靳有鹏 王莹[7] 刘春峰[8] 成怡冰 杨巧芝[10] 肖曙芳[11] 杨镒宇 霍习敏[13] 雷智贤 党红星[2] 刘霜[4] 武志远 李科纯 钱素云[1] 曾健生[1] Fang Boliang;Xu Feng;Lu Guoping;Ren Xiaoxu;Zhang Yucai;Jin Youpeng;Wang Ying;Liu Chunfeng;Cheng Yibing;Yang Qiaozhi;Xiao Shufang;Yang Yiyu;Huo Ximin;Lei Zhixian;Dang Hongxing;Liu Shuang;Wu Zhiyuan;Li Kechun;Qian Suyun;Zeng Jiansheng(Department of Pediatric Intensive Care Unit,Beijing Children′s Hospital,Capital Medical University,National Center for Children′s Health,Beijing 100045,China;Department of Pediatric Intensive Care Unit,Children′s Hospital of Chongqing Medical University,Chongqing 400014,China;Department of Pediatric Intensive Care Unit,Children′s Hospital of Fudan University,Shanghai 201102,China;Department of Pediatric Intensive Care Unit,Children′s Hospital Affiliated to Capital Institute of Pediatrics,Beijing 100020,China;Department of Critical Care Medicine,Shanghai Children′s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200062,China;Department of Pediatric Intensive Care Unit,Shandong Provincial Hospital Affiliated to Shandong First Medical University,Jinan 250021,China;Department of Pediatric Critical Care Medicine Unit,Shanghai Children′s Medical Center,Shanghai Jiao Tong University School of Medicine,Shanghai 200127,China;Department of Pediatric Intensive Care Unit,Shengjing Hospital of China Medical University,Shenyang 110004,China;Department of Pediatric Intensive Care Unit,Henan Children′s Hospital,Zhengzhou 450000,China;Department of Pediatric Intensive Care Unit,Liaocheng People′s Hospital,Liaocheng 252000,China;Department of Pediatric Intensive Care Unit,Kunming Children′s Hospital,Kunming 650034,China;Department of Pediatric Intensive Care Unit,Guangzhou Women and Children′s Medical Center,Guangzhou 510623,China;Department of Pediatric Intensive Care Unit,Hebei Children′s Hospital,Shijiazhuang 050031,China;Department of Pediatric Intensive Care Unit,Hainan Women and Children′s Medical Center,Haikou 570206,China)

机构地区：[1]国家儿童医学中心、首都医科大学附属北京儿童医院重症医学科,北京100045 [2]重庆医科大学附属儿童医院重症医学科,重庆400014 [3]复旦大学附属儿科医院重症医学科,上海201102 [4]首都儿科研究所附属儿童医院重症医学科,北京100020 [5]上海交通大学医学院附属儿童医院、上海市儿童医院重症医学科,上海200062 [6]山东第一医科大学附属省立医院小儿重症医学科,济南250021 [7]上海交通大学医学院附属上海儿童医学中心重症医学科,上海200127 [8]中国医科大学附属盛京医院小儿急诊急救内科,沈阳110004 [9]河南省儿童医院重症医学科,郑州450000 [10]聊城市人民医院重症医学科,聊城252000 [11]昆明市儿童医院重症医学科,昆明650034 [12]广州妇女儿童医学中心重症医学科,广州510623 [13]河北省儿童医院重症医学科,石家庄050031 [14]海南省妇女儿童医学中心重症医学科,海口570206

出　　处：《中华儿科杂志》2023年第3期216-221,共6页Chinese Journal of Pediatrics

基　　金：国家临床重点专科建设项目(〔2021〕451);吴阶平医学基金会临床科研专项(320.6750.17192)。

摘　　要：目的分析儿童重症监护病房(PICU)内儿童急性呼吸窘迫综合征(PARDS)死亡风险因素。方法对“肺表面活性物质治疗婴幼儿中重度PARDS疗效分析”所建立的临床数据库资料进行二次分析。回顾性病例总结2016年12月至2021年12月中国14家三甲医院PICU的101例中重度PARDS婴幼儿的死亡风险因素。根据患儿出PICU时情况分为死亡组和存活组,比较一般情况、基础疾病、氧合指数、机械通气等临床资料差异。组间比较采用Mann-Whitney U检验或χ^(2)检验。采用受试者工作特征(ROC)曲线评估氧合指数预测病死率的准确性。采用多因素Logistic回归分析死亡风险因素。结果101例中重度PARDS婴幼儿中男63例(62.4%)、女38例(37.6%),年龄为(12±8)月龄。死亡组患儿23例,存活组患儿78例。死亡组中合并基础疾病及免疫缺陷患儿比例均高于存活组[52.2%(12/23)比29.5%(23/78),30.4%(7/23)比11.5%(9/78),χ^(2)=4.04、4.76,P=0.045、0.029],肺表面活性物质(PS)使用率低于存活组[8.7%(2/23)比41.0%(32/78),χ^(2)=8.31,P=0.004]。年龄、性别、小儿危重症评分、PARDS病因、机械通气模式、72 h内液体平衡情况2组间差异均无统计学意义(均P>0.05)。死亡组PARDS治疗第1~3天氧合指数值均高于存活组[11.9(8.3,17.1)比15.5(11.7,23.0)、10.1(7.6,16.6)比14.8(9.3,26.2)、9.2(6.6,16.6)比16.7(11.2,31.4),Z=-2.70、-2.52、-3.79,均P<0.05]。死亡组治疗3 d后氧合指数改善程度较存活组更差[0.03(-0.32,0.31)比0.32(-0.02,0.56),Z=-2.49,P=0.013]。ROC曲线分析示第3天的氧合指数值对中重度婴幼儿PARDS死亡预测的准确度较好(曲线下面积=0.76,标准误=0.05,95%CI 0.65~0.87,P<0.001);当氧合指数取值11.1时,灵敏度78.3%(95%CI 58.1%~90.3%),特异度60.3%(95%CI 49.2%~70.4%)。多因素Logistic回归分析显示,在校正了年龄、性别、小儿危重病评分和72 h内液体负荷情况后,未使用PS(OR=11.26,95%CI 2.19~57.95,P=0.004)、第3天氧合指数值(OR=7.93,95%CObjective To identify the risk factors in mortality of pediatric acute respiratory distress syndrome(PARDS)in pediatric intensive care unit(PICU).Methods Second analysis of the data collected in the“efficacy of pulmonary surfactant(PS)in the treatment of children with moderate to severe PARDS”program.Retrospective case summary of the risk factors of mortality of children with moderate to severe PARDS who admitted in 14 participating tertiary PICU between December 2016 to December 2021.Differences in general condition,underlying diseases,oxygenation index,and mechanical ventilation were compared after the group was divided by survival at PICU discharge.When comparing between groups,the Mann-Whitney U test was used for measurement data,and the chi-square test was used for counting data.Receiver Operating Characteristic(ROC)curves were used to assess the accuracy of oxygen index(OI)in predicting mortality.Multivariate Logistic regression analysis was used to identify the risk factors for mortality.Results Among 101 children with moderate to severe PARDS,63(62.4%)were males,38(37.6%)were females,aged(12±8)months.There were 23 cases in the non-survival group and 78 cases in the survival group.The combined rates of underlying diseases(52.2%(12/23)vs.29.5%(23/78),χ^(2)=4.04,P=0.045)and immune deficiency(30.4%(7/23)vs.11.5%(9/78),χ^(2)=4.76,P=0.029)in non-survival patients were significantly higher than those in survival patients,while the use of pulmonary surfactant(PS)was significantly lower(8.7%(2/23)vs.41.0%(32/78),χ^(2)=8.31,P=0.004).No significant differences existed in age,sex,pediatric critical illness score,etiology of PARDS,mechanical ventilation mode and fluid balance within 72 h(all P>0.05).OI on the first day(11.9(8.3,17.1)vs.15.5(11.7,23.0)),the second day(10.1(7.6,16.6)vs.14.8(9.3,26.2))and the third day(9.2(6.6,16.6)vs.16.7(11.2,31.4))after PARDS identified were all higher in non-survival group compared to survival group(Z=-2.70,-2.52,-3.79 respectively,all P<0.05),and the improvement of OI in non

关 键 词：医院 儿科 重症监护病房 病死率 呼吸窘迫综合征 

分 类 号：R725.6[医药卫生—儿科]