Pediatric Critical Illness Score Research Articles

Plasma exchange combined continuous veno-venous hemodiafiltration in the treatment of critical hemolytic uremic syndrome

Objective To investigate the efficacy of bedside plasma exchange(PE) combined continuous veno-venous hemodiafiltration(CVVHDF) in children with critical hemolytic uremic syndrome(HUS). Methods Eight patients with HUS from Pediatric Intensive Care Unit of Shanghai Children′s Hospital were included in the present study.The severity of children was graded according to pediatric critical illness score and pediatric risk of score mortality Ⅲ.Four of them received continuous blood purification treatment.Meanwhile, the clinical manifestation and outcome of HUS were analyzed. Results Eight children with HUS were initially treated with diuretic and blood transfusion for 12-24 hours.Four cases who deteriorated aggressively were performed PE and CVVHDF.Plasauto iQ21 and Prisma flex were used with Prisma TPE 2000 membrane plasma separator and AN69 M60 membrane filter respectively.All the 4 patients with critical HUS survived after bedside continuous blood purification treatment.Clinical symptoms and serum biochemistry were improved significantly as follows.The average levels of serum creatinine and lactate dehydrogenase decreased obviously(318 μmol/L vs. 162 μmol/L; 1 963 U/L vs. 407 U/L, respectively). In addition, platelet count increased significantly(40×109/L vs. 97×109/L). Eventually, symptoms disappeared in these 4 patients. Conclusion The combined therapy of PE and CVVHDF in HUS could stabilize fluid acid-base equilibrium, prevent hemolysis and improve the renal function. Key words: Plasma exchange; Continuous veno-venous hemodiafiltration; Hemolytic uremic syndrome; Critically ill; Children

Applying a discriminant model based on combination of pediatric critical illness score,D-dimer and procalcitonin in early predicting the severity of pediatric infection

Objective To establish a discriminant method based on clinical and laboratory data and common examinations for early predicting the severity of pediatric infection. Methods Consecutive hospitalized patients diagnosed as septic shock were included who were admitted between June 2014 and May 2015 retrospectively.Gender (male-female ratio: 1.251.00)and age (1 month to 6 years old) were matched in all of 18 patients with septic shock, and 27 patients diagnosed as systemic inflammatory response syndrome (SIRS), sepsis and severe sepsis on admission were included respectively in order of sequential admission number during the same period.Additional 36 gender- and age-matched children with common infection (non-SIRS)were enrolled as controls.The clinical and laboratory examination data of all the included patients were collected and then the pediatric critical illness scores (PCIS)were made according to the worst condition within 24 hours of hospitalization.The parameters correlated with the severity of infection were evaluated by rank correlation and Logistic regression analysis.The discriminant models were established based on κth-nearest-neighbor analysis and evaluated with clinical diagnosis by interrater agreement test. Results Except for platelet count, the other indexes including PCIS, neutrophil count, C-reactive protein, procalcitonin (PCT), international normalized ratio of prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen, fibrin/fibrinogen degradation product (FDP)and D-dimer (D-D)all had differences among groups with varying infection severity (all P<0.001). The Spearman's coefficient ρ of PCIS, PCT, D-D and FDP correlated to infection severity were -0.837, 0.680, 0.679 and 0.648, respectively (all P<0.001). Multivariate cumulative odds Logistic regression analysis showed PCIS, D-D and PCT were related to infection severity (all P<0.05). The total error rate of discriminant models based on 3-index combination (Mahalanobis transformation, k=2)was 0.091 that was lower than any models based on 2-index combination or single-index.Using the discriminant model based on three-index combination, the infection severity of 26 patients admitted during June 2015 were predicted with a high interrater agreement (weighted Kappa coefficient: 0.670, P<0.001)compared to clinical diagnosis. Conclusion The discriminant model based on combination of PCIS, D-D and PCT could assist predicting the severity of pediatric infection earlier. Key words: Infection; Discriminant analysis; Pediatric critical illness score; D-dimer; Procalcitonin

Assessment of energy metabolism and nutritional supply in children with mechanical ventilation

To determine the resting energy expenditure on mechanical ventilation in pediatric intensive care unit (PICU) by indirect calorimetry, and analyze the distribution of metabolic states. The nutrition supply was assessed according to the resting energy expenditure. An observational study which was held in PICU of Beijing Children's Hospital from November 2013 to April 2014. Critically ill children with mechanical ventilation were enrolled in this study. The inclusion criteria included the following: (1) pediatric critical illness score < 90, or meet the United States PICU admission criteria; (2) age > 29 days, < 18 years old; (3) time of mechanical ventilation > 24 hours; (4) volume of mechanical ventilation > 60 ml. Resting energy expenditure was determined by US Med Graphic Company CCM/D energy metabolism test system. Predictive resting energy expenditure was calculated for each subject with age-appropriate equation (Schofield-HTWT). According to the actual energy intake records and required energy intake (10% higher than the measured value) to define the nutritional status. The selected subjects were grouped according to gender, age, types of disease and nutritional status, and compared the metabolic status and nutritional supply of different groups. Sixty-eight children were enrolled in this study, 46 were boys and 22 were girls, including 25 cases of pneumonia with respiratory failure, 23 cases of central nervous system diseases complicated with respiratory failure and 20 cases of postoperative tracheal intubation. The ratio of boys and girls was 2:1. The results showed 36 patients in a low metabolic state, accounting for 53%, 23 patients in a high metabolic state, accounting for 34% and 9 patients (13%) in the metabolism of the normal state. In the male children, 12 cases (26%) were in the high metabolism and 26 cases (57%) were in the low metabolism, and 8 cases (17%) were in the normal metabolism. In the female children, 11 cases (50%) were classified into high metabolism; 10 cases (45%) into low metabolism and 1 case (5%) was classified into normal metabolism. There was no significant difference in the distribution of metabolic status among different gender(χ(2) = 4.176, P = 0.095). In terms of ages, 15 cases (63%) were mainly in high metabolism in the patients at age < 3 years, 19 and 11 patients in 3-9 and 10-18 years age group respectively are mostly in low metabolism. As to the diseases, pneumonia complicated with respiratory failure and central nervous system diseases complicated with respiratory failure with mechanical ventilation (respectively 15 cases (60%) and 12 cases (52%)) were in low metabolism mainly; 11 cases of postoperative tracheal intubation were in high metabolism states, accounting for 55%. The distribution of metabolic status in different age and clinical diagnosis had significant difference. Thirty-one patients had normal nutrients supply, accounting for 46%, 37 patients had inappropriate nutrition supply, accounting for 54%, including insufficient supplies of nutrients in 22 cases, accounting for 32%, excessive supplies of nutrients were seen in 15 cases(22%). There were no statistically significant differences among the different types of diseases. There are differences in the metabolic state of the mechanical ventilation in critically ill patients, mainly in low metabolic state. The age and types of diseases can affect the metabolic status of patients. Empirical nutritional support is not applicable to patients.

Prognostic value of N-terminal pro-brain natriuretic peptide levels in critically ill infants

Objective To explore the prognostic value of N-terminal pro-brain natriuretic peptide(NT-pro-BNP) levels in critically ill infants. Methods Eighty-one critically ill infants were enrolled from January 2013 to January 2014 in pediatric intensive care unit.The minimum of pediatric critical illness score(PCIS) and the number of dysfunction organs were calculated within 24 hour after admission.According to PCIS, the critically ill infants were divided into extremely critical group(PCIS≤70, n=25), critical group(PCIS 71-80, n=30)and non-critical group(PCIS>80, n=26). According to the prognosis, the critically ill infants were divided into survival group(n=68)and death group(n=13). The serum NT-pro-BNP levels were determined on the first day, third day and convalescent phase.The relationships of serum NT-pro-BNP levels with PCIS and the number of dysfunction organs and prognosis were observed. Results The study showed statistical significances of serum NT-pro-BNP levels among the extremely critical group, critical group and non-critical group, whether on the first day, or on the third day and convalescent phase(P<0.01). There were statistical significances of serum NT-pro-BNP levels among different stages of the disease in each group(P<0.01). Compared with survival group, PCIS was significantly lower and the serum NT-pro-BNP levels and the number of dysfunction organs were significantly higher in death group.The serum NT-pro-BNP level on the third day was higher than that on the first day in death group(P<0.01), while no significant difference was found in survival group.The serum NT-pro-BNP levels on the first day and the third day and PCIS were negatively correlated(r=-0.59, P<0.01; r=-0.66, P<0.01). The serum NT-pro-BNP levels on the first day and the third day and the number of dysfunction organs were positively correlated(r=0.40, P<0.05; r=0.57, P<0.01). Conclusion The serum NT-pro-BNP levels of the critically ill infants are correlated with disease severity, and can be useful for assessing the severity of critical illness. Key words: Critical illness; Infants; N-terminal pro-brain natriuretic peptide; Prognosis

Clinical significance of soluble P-selectin in children with severe pneumonia accompanying sepsis

Objective To study the relevancy between soluble P-selectin and other clinical biomarkers, pe-diatric critical illness score in children with severe pneumonia accompanying sepsis, and to discuss the clinical significance of soluble P-selectin in children with severe pneumonia accompanying sepsis. Methods One hundred and twenty-six children with severe pneumonia accompanying sepsis admitted to the Pediatric Intensive Care Unit were selected from January of 2010 to December of 2013 as research subjects.They were divided into the following groups according to their severity of their: sepsis group(n=71), severe sepsis group(n=42) and septic shock group(n=13). Their biomarkers were detected within 2 h after admission.The data were analyzed by SPSS 11.0 software, multiple linear regression analysis was made to evaluate the relationship between clinical biomarkers, pediatric critical illness score and soluble P-selectin. Results (1) The average level of soluble P-selectin, blood lactate, D-Dimer and interleukin-6 level increased, platelet count level decreased in 3 groups, and there were significant differences among 3 groups(P<0.05). (2)In this research, there were positive correlation between interleukin-6, D-Dimer and soluble P-selectin but negative correlation between pediatric critical illness score and soluble P-selectin. Conclusions The concentration of the soluble P-selectin may have very important clinical value in the early diagnosis and the prognosis of children with severe pneumonia accompanying sepsis. Key words: Sepsis; Severe pneumonia; Child; Biomarker; Soluble P-selectin

Clinical characteristics of severe pneumocystis pneumonia in children without human immunodeficiency virus infection

Objective To investigate the clinical parameters, risk factors, treatment and clinical outcomes of pneumocystis pneumonia(PCP) in children without human immunodeficiency virus(HIV). Methods Retrospective analysis was made for the clinical features, risk factors, treatment and prognoses of the non-HIV infected severe PCP patients hospitalized at Pediatric Intensive Care Unit(PICU) of Children's Hospital Affiliated to Capital Institute of Pediatrics. Results During April of 2010 to April of 2014, there were 10 cases of non-HIV infected severe PCP in PICU of Children's Hospital Affiliated to Capital Institute of Pediatrics.All of the patients had predisposing diseases, in which 3 cases had connective tissue diseases, 2 cases had acute leukemia, 3 cases had severe pneumonia and 2 cases had congenital immunodeficiency.The main clinical manifestations of those 10 patients were fever, cough, tachypnea and obvious dyspnea.All patients developed respiratory failure.The median value of Pediatric Critical Illness Score was 79.The median arterial oxygen pressure was 58 mmHg(1 mmHg=0.133 kPa). The median oxygenation index was 103 mmHg. The median alveolo-arterial oxygen partial pressure difference was 43.8 mmHg. The median CD4+ T-lymphocytes counts was 169×106/L. Eight patients on admission had mixed infection.Acute respiratory distress syndrome(ARDS) occurred in all of the patients, and 7 cases of them had multiple organ dysfunctions.All of the patients required ventilation support.The median day for invasive mechanical ventilation days was 11 and the median day for noninvasive ventilation days was 6.The pneumothorax occurred in 5 patients.All patients received trimethoprim-Sulfamethoxazole as initial therapy and Caspofungin treatment in combination in 7 cases of the patients.Six patients had nosocomial infection. The median time of PICU stay was 15.5 days.Six patients survived and the mortality was 40%(4/10 cases). Conclusions PCP is a kind of fatal diseases which occurred in patients with immunocompromised conditions and concurrent ARDS or multiple organ dysfunctions.Diagnostic suspicion and mechanical ventilation therapy with lung protective ventilation strategies may improve the clinical outcomes of non-HIV-infected PCP in children. Key words: Pneumocystis pneumonia; Acute respiratory distress syndrome; Treatment; Child

Outcome follow-up and reason analysis in long PICU stay patients

Objective To analyse the reasons for patients′ long PICU stay and to discuss how to decrease their PICU stay length and optimize medical resource utilization.The another objective is to identify these patients′ long-term outcome. Methods We retrospectively analysed the basic information of patients who stayed in our PICU more than 30 days during January 1, 2013 to July 31, 2014, including pediatric critical illness score on admission, primary diseases and outcome on discharge, in order to determine main reasons for their long PICU stay.Follow-up prognosis was made by Paediatric Overall Performance Category.We used SPSS 19.0 to do data analysis. Results Sixty-seven patients enrolled in this study included 43 boys and 24 girls, 49.2% of whom came from emergency department.The median age was 24 months(IQR 8, 108), while median length of PICU stay was 39 days(IQR 31, 49). Mean pediatric critical illness score on admi-ssion was 78.39±9.57.Mean hospital fees was(144 071.74±76 944.74) Yuan.Thirty(44.8%) patients did not have any medical insurance.Top three primary diseases were respiratory disease(30 cases), neurological disease(8 cases) and systemic infection(6 cases). Top three underlying diseases were tracheostenosis or bronchopulmonary dysplasia(6 cases), congenital heart disease(5 cases) and immunodeficiencies(4 cases). Top three complications were respiratory failure(30 cases), multiple organ dysfunction or failure(16 cases), shock(9 cases). Top three reasons for longer PICU stay were weaning off mechanical ventilation difficulty(29 cases), department or hospital transference difficulty(20 cases), feeding difficulty(16 cases). Fifty-four patients were discharged with better health condition, 10 patients were auto-discharge.The mortality at discharge, 1 month after discharge, 3 months after discharge and 6 months after discharge were 4.5%, 20.9%, 25.4% and 25.4%, respectively.Total 36(53.7%) patients had a good or mildly abnormal Paediatric Overall Performame Category score(1-2 points) at 6 months after discharge. Conclusion Sequential noninvasive ventilation, timely tracheotomy, timely patients′ transference to general ward, development of family ward and rehabilitation wards, appropriate nutrition delivery, regularly difficult disease consultation, reduction of hospital infection and complications may do contribution to shorten these patients′ length of PICU stay.Children who survive longer than 3 months after discharge have better long-term prognosis. Key words: Pediatric intensive care unit; Length of hospital; Reason; Prognosis,

Effect of 3% hypertonic saline as early fluid resuscitation in pediatric septic shock

The mainstay of therapy in patients with septic shock is early and aggressive intravenous fluid resuscitation. However the type of intravenous fluid that would be ideal for managing septic shock has been intensely debated. In this study, the authors observed the effects of 3% hypertonic saline solution compared with normal saline solution as early fluid resuscitation in children with septic shock. In this prospective study, 44 septic shock children seen in the intensive care unit (ICU) of the Children's Hospital Affiliated to Capital Institute of Pediatrics were enrolled from January 2012 to January 2014, of whom 33 were male and 11 were female. Patients were randomly divided into two groups: normal saline group (NS group, 24 patients) and 3% hypertonic saline group (HS group,20 patients). There were no significant differences between the 2 groups of patients in age, gender, pediatric critical illness score (PCIS), oxygenation index (OI = PaO2/FiO2), arterial lactate, initial hemodynamic parameters, serum sodium and treatment at time of admission. Patients in NS group received normal saline guided by standard therapy. Those in HS group received 6 ml/kg 3% hypertonic saline as a single bolus over 10 min to 15 min with a maximum of 2 boluses and other standard therapy. Heart rate (HR), mean arterial blood pressure (MAP), arterial lactate, oxygenation index, urine output, serum sodium, lactate clearance rate, PCIS, fluid infusion volume, vasoactive - inotropic score, mechanical ventilation time , as well as incidence of multiple organ dysfunction syndrome (MODS), and 28 days in - hospital mortality were recorded for all patients. (1) HR, MAP in both groups were significantly higher after infusion than those on admission. There were no significant difference in HR and MAP at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (2) OI in HS group was significantly higher than that on admission at 3 hours after infusion [(321. 8 ± 50. 7) vs. (296. 5 ± 58. 2) mmHg, t = -2. 50, P = 0. 018 ]), and it was significantly higher at 24 hours after infusion in NS group (325. 7 ± 62. 6) vs. (304. 2 ± 70. 4) mmHg, t = -2.60, P=0.016]. There were no significant differences in OI at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (3) At 1 hour after infusion, serum sodium in HS group was significantly higherthan that in NS group [(138.3 ± 3.8)vs. (135.0 ± 3.5) mmol/L, t=8.77, P=0.005], and then no significant difference at 3h, 6h and 24h after infusion between two groups. (4) At 6 hours and 24 hours after treatment, fluid infusion volume in HS group was markedly less than that in NS group [6 h: (39. 2 13. 9) vs. (60. 8 ± 22. 4) ml/kg, t = 14. 21, P =0. 000; 24 h: (102. 9 ± 27. 7) vs. (130. 6 ± 33. 2 ) ml/kg, t= 8. 85, P = 0. 005]. Urine output had not significant different between the two groups. (5) There were no significant differences in 24h PCIS, 24h lactate clearance rate, vasoactive - inotropic score and mechanical ventilation time between the two groups. The incidence of MODS (80. 0% in HS group, 70. 0% in NS group) and mortality rate(5. 0% in HS group, 8. 3% in NS group) were similar in both groups. The 3% hypertonic saline was effective as resuscitation fluid in pediatric septic shock with respect to restoration of hemodynamic stability without obvious side effects. Hypertonic saline could more rapidly improve oxygenation and need less fluid infusion volume compared with normal saline.

The value of N-terminal pro-Brain Natriuretic Peptide in children with severe hand-foot-mouth disease

Objective To explore the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in assessing severity and predicting prognosis in children with severe hand-foot-mouth disease (HFMD). Methods A total of 119 eligible children with severe HFMD admitted in the pediatric intensive care unit were enrolled in this retrospective study from March 2012 to March 2014. According to NT-proBNP level, children were divided into ≤ 500 pg/mL group (n =70) and >500 pg/mL group (n =49) ; whereas according to severity, children were divided into severe-type (n =74) and critical-type (n =45) ; and based on 28 days outcome in children with critical-type HFMD, children were divided into fatal group (n =27) and survival group (n =18). The chi-square test, two-samplet test, rank sum test Pearson or Spearman' s correlation , area under the receiver operating characteristic curve (AUC) were used to analyze119 children with severe hand-foot-mouth disease (HFMD). Results Within 24 hours after admission, NT-proBNP>500 pg /mL group had higher rates of fever, abnormal breathing, abnormal heart rate, abnormal systolic blood pressure, capillary refill time >2 seconds and higher levels of laboratory biomarkers than NT-proBNP ≤ 500 pg/mL group (P <0.05) ; and during hospitalization, the rates of pulmonary edema, pulmonary hemorrhage and death also higher than NT-proBNP ≤ 500 pg/mL group (P <0.05 ). NT-proBNP, BS, WBC were higher in critical-type group than severe-type group (P =0.00) , while the PCIS (pediatric critical illness score) was lower in critical-type group (χ2 =14.70 , P =0.00). NT-proBNP was higher in fatal group than that in survival group (t =-2.60 , P =0.01) , PCIS was lower in fatal group (Z =2.70 , P =0.01) ; and there were no statistically significant differences in BS and WBC between fatal and survival groups (BS : t =-0.60 , P =0.55 ; WBC : t =-0.72 , P =0.48). NT-proBNP, BS and WBC were negatively correlated with PCIS (r values were -0.58 , -0.46, -0.56 , P values were 0.00). The AUCs of NT-proBNP, BS, WBC and PCIS to determine the severity of severe HFMD children were 0.94, 0.80, 0.74, and 0.97, respectively; and to predict 28 days survival in critical-type HFMD were 0.73 , 0.56 , 0.53 , and 0.73 , respectively. Conclusions Higher level of NT-proBNP could prompt cardiopulmonary involvement. NT-proBNP could reflect the severity of illness and served as a sensitive marker in predicting 28-day survival, being better than BS and WBC. Key words: N-terminal pro-brain natriuretic peptide; Severe; Hand-foot-mouth disease; Cardiopulmonary function; Pediatric critical illness score; Blood sugar; White blood cell; Prognosis

Nutritional assessment in a pediatric intensive care unit

Objective To assess nutritional status of critically ill children, and to investigate the correlation of nutritional status with illness severity and clinical outcomes, so as to provide a theoretical basis for rational nutrition support of critically ill children. Methods All patients hospitalized in the pediatric intensive care unit of Beijing Children' s Hospital from November, 2010 to January 2011 were enrolled and studied prospectively. We collected anthropometric parameters (body length/height, body weight, head circumference, etc) for nutritional assessment, as well as their clinical data such as underlying diseases, pediatric risk of mortality scores (PRISM) , length of hospital stay and mechanical ventilation duration. Results In 196 cases , the prevalence of malnutrition was 21.9% (43/196). Malnutrition group had greater PRISM scores, higher mechanical ventilation rate and a lower 28-day survival rate than normal nutritional status group (allP <0.05). Conclusions The prevalence of malnutrition on admission to the PICU was high and poor nutritional status indicated greater illness severity and adverse clinical outcomes Key words: Critical illness; Malnutrition; Anthropometry; Nutritional status; Pediatric critical illness score; Pediatric risk of mortality scores; Severity of diseases; Clinical outcomes.

Increase of procalcitonin in infant muggy syndrome

Objective To investigate the characteristics and clinical significance of increased procalcitonin(PCT) in infant muggy syndrome(IMS). Methods A total of 23 IMS cases admitted in PICU from Nov 2011 to Apr 2012 were enrolled.All cases were devided into three groups according to pediatric critical illness score, high risk group(n=5), medium risk group(n=12), and mild risk group(n=6). And 23 cases were also divided into infection group and no infection group according to baseline disease before onset.The relationship of PCT and pediatric critical illness score, primary infection and infection index were observed, and the possible causes of increased PCT in IMS were explored.Twenty age matched infants receiving examination in clinic served as control group. Results PCT increased significantly in IMS cases.The PCT level was(91.5±90.9) ng/ml in high risk group, (81.1±74.1) ng/ml in medium risk group, and(112.1±74.9) ng/ml in mild risk group, there were no significant differences among three groups(F=0.371, P=0.732). Other infection index like leukocyte conmt, neutrophil and C reactive protein in IMS group were higher than those in the control group, and the results had significant differences(P<0.05, respectively). The PCT level was(72.5±74.4) ng/ml in infection group, (101.5±76.6) ng/ml in no infection group, and there was no significant difference between two groups(t=0.873, P=0.392). There was no relevance between increase of PCT and the incidence of infection before IMS.But PCT had higher correlation to the body temperature after IMS(r=-0.362, P=0.049). Conclusion There is correlation between the increased PCT and fever in IMS, and fever in IMS would lead to inflammation and then resulted in the increase of PCT. Key words: Infant muggy syndrome; Procalcitonin

The risk factors for mortality in non-human immunodeficiency virus infected children with pneumocystis carinii pneumonia

Objective To analyze the epidemiologic characteristics and risk factors for mortality in non-(human immunodeficiency virus, HIV) infected children with pneumocystis carinii pneumonia(PCP). Methods The data of non-HIV infected children with PCP diagnosed in Beijing Children's Hospital from January 1, 2006 to December 31, 2012 were collected.They were divided into survival and non-survival group according to the prognosis.The epidemiologic characteristics and risk factors for mortality were analyzed. Results Sixteen patients were enrolled in this study.Ten of them survived and 6 of them were non-survived.The basic diseases included malignant tumor in 5 patients and non-malignancy diseases in 11 of them.Compared with the survival group, the non-survival group had a higher average age [(12.00±2.00)years vs.(6.65±4.32)years, P=0.01], higher ratio to need mechanical ventilation (6/6 vs.4/10, P=0.04), lower PaO2/FiO2[(73.88±26.95) mmHg vs.(167.50±97.17) mmHg, 1 mmHg=0.133 kPa, P=0.01] and lower pediatric critical illness score(75.67±5.72 vs.86.40±8.88, P=0.02). There were no differences on sex ratio, kinds of basic diseases, whether with co-infections, the time of immunosuppressant administration, the time from onset to diagnosis, the time from onset to beginning trimethoprim-sulfamethoxazole therapy, PaCO2, white blood cell counts, lymphocyte counts, cell counts, C-reactive protein, and hemoglobin concentrations between the survival and non-survival group. Conclusion A higher age, need for mechanical ventilation, lower PaO2/FiO2 and lower pediatric critical illness score were risk factors for mortality in non-HIV infected children with PCP. Key words: Non-human immunodeficiency virus infection; Pneumocystis carinii pneumonia; Epidemiology; Risk factors; Mortality; Children

The study of clinical applying continuous hemofiltration in children severe hand-foot-and-mouth disease with cardiopulmonary failure

Objective To analyze the clinical value of continuous veno-venous hemofiltration (CVVH) treatment in children with severe hand-foot-and-mouth disease (HFMD) complicated with cardio-pulmonary failure, via the prognostic comparison of the general comprehensive treatment and CVVH add-on treatment. Methods Fifty-one cases of severe HFMD with cardiopulmonary failure were divided into a CVVH group (n=19) and a control group (n=32) based on whether CVVH add-on or not. Their physiological and biochemical indicators were recorded and pediatric critical illness score (PCIS) and pediatric risk of mortality score (PRISM III) were calculated within 24 hours, when they were diagnosed with neurogenic pulmonary edema (NPE) /pulmonary hemorrhage. Both groups were treated with endotracheal intubation, mechanical ventilation with high PEEP, corticosteroids, ulinastatin, actively lowering the intracranial pressure, fluid resuscitation, milrinone, dopamine and other vasoactive drugs, high-dose intravenous gamma globulin, the CVVH group were added with CVVH treatment (duration>12 h). Prognosis difference of CVVH add-on treatment after diagnosed with NPE/pulmonary hemorrhage by tracking indicators of the third day. Survival analysis between two groups were compared by 3-day survival rates, 7-day survival rates, 28-day survival rates and the finally survival rates. Results (1) The overall conditions of two groups were comparable when diagnosed with NPE/pulmonary hemorrhage. PCIS, PRISM III, WBC counting, lactic acid, micro-blood sugar, myocardial enzymes and liver enzymes showed no significant difference between two groups. Three days after treatment, WBC and lactic acid decreased, but there was no significant difference (P>0.05), the remaining indicators had significantly improved in the CVVH group than those in the control group (P<0.05). (2) The 3-day survival rate, 7-day survival rate, 28-day survival rate and the finally survival rates in control group and CVVH group were 40.63 % vs.84.21%, 37.50% vs.73.68%, 25.00% vs.63.16%, 18.75% vs.52.63%, the survival rate in CVVH group were significantly higher (P<0.05). (3) The survival curve indicated that the survival time of CVVH group was significantly longer than that of the control group, the median survival time were 17 d and 2 d, respectively, and the difference was statistically significant (P<0.05). (4) In the CVVH group, 15 cases received CVVH after diagnosed with NPE/pulmonary hemorrhage within 12 hours, of which 10 cases (66.67%) ultimately survived, while the other 4 cases received CVVH after 12 h were all end to death, the difference was statistically significant (P<0.05). Further analysis of the impact of the timing of blood purification on the prognosis of children showed that the mortality rates of children received CVVH within 6 hours, 6 to 12 hours, after 12 hours of diagnosis of NPE/pulmonary hemorrhage, were 2/8, 3/7, 4/4, respectively. Conclusion Continuous hemofiltration can significantly improve the prognosis of children with severe HFMD, and may be preferable to perform in early stage. Key words: Continuous hemofiltration; Severe hand-foot-mouth disease; Cardiopulmonary failure; Children

Noninvasive pulmonary arterial pressure monitoring in the children with severe pneumonia and respiratory failures and its significance

Objective To evaluate the value of noninvasive monitoring of pulmonary arterial pressure in the children with severe pneumonia and respiratory failure. Methods A prospective study was adopted to investigate 69 patients who suffered from severe pneumonia and respiratory failure in Pediatric Intensive Care Unit in Shanghai Children's Hospital from June 2013 to December 2013 were involved in this study, except for heart disease.The pulmonary arterial pressure (PAP) and cardiac function were monitored by using bedside color doppler ultrasound cardiogram, such as PAP, cardiac index (CI), left ventricle ejection fraction(LEFT), and heart early diastolic filling velocity maximum/heart late diastolic filling velocity maximum (E/A ratio). They were divided into 2 groups according to PAP, one group as pulmonary arterial pressure normal group, the other group as pulmonary arterial hypertension(PAH) group, and the impact of the PAP on the prognosis and mechanical ventilation was assessed.Milrinone[0.5 μg/(kg·min)]were given the patients who were combined with pulmonary hypertension, and the PAP and cardiac function before using Milrinone and 24 h, 48 h and 72 h after giving medicine was observed. Results Among 69 cases, 40 cases were male and 29 cases were female, age ranging from 2 months to 12 years old, and the weight range was (14.3±8.9) kg.The pe-diatric critical illness score(PICS) was 70.5±9.6, and the pediatric risk of score mortalityⅢ was 13.5±5.0.Among 69 cases, 46 cases had pulmonary arterial hypertension, 38 cases of them experienced mechanical ventilation, and 9 cases died.Among 23 cases who had no pulmonary arterial hypertension, only 8 cases experienced mechanical ventilation.There was a significant difference in the mechanical ventilation rate and mortality between two groups(χ2=15.78, P 0.05). However, 9 cases of them did not show any response to Milrinone, and in the end they couldn't live without mechanical ventilation, they died. Conclusions Noninvasive pulmonary arterial pressure monitoring could be beneficial in judging patient's condition and assessing prognosis of children with severe pneumonia and respiratory failure, and milrinone could decrease PAP. Key words: Pulmonary arterial hypertension; Color doppler ultrasound cardiogram; Pneumonia, severe; Respi-ratory failure; Milrinone; Child

Application of the severity score of hand foot and mouth disease in children

Objective To develop the severity score of pediatric hand foot and mouth disease (HFMD),guide health care providers in the early detection and intervention of critical ill cases,in order to improve the survival rate and reduce the incidence of complications and mortality.Methods Based on PCIS,the severity score of HFMD in children was designed by adding fever and nervous system damage symptoms,which was the common symptoms of severe cases.The data of the cases who admitted in April 2008 to November 2010 (group A,88 cases) was retrospectively analyzed to evaluate the validity and credibility of the score.The score were prospectively applied to all of the HFMD cases who admitted from May 2011 to October 2013(group B,118 cases),delivering corresponding treatment and care measures based on scoring result as well.At last the outcome of the two groups was compared.Results It exhibited quite good consistency between the scores and the clinical condition of patients with HFMD.The general information of two groups was not significantly different,but the survival rate,the incidence of neurological sequel and the mortality between two groups were significantly different by x2 test.Conclusions The score can objectively and accurately assess the severity of HFMD in children.Clinical application of this scoring method to assess the children with HFMD can identify critical ill cases as early as possible.Corresponding intervention delivering in time may improve the outcome.It is proved to have positive clinical value to increase the survival rate,decrease the incidence of neurological sequel and the mortality of critical ill HFMD cases,and is worthy of clinical application in pediatric department. Key words: Hand, foot and mouth disease; Pediatric critical illness score; Assessment

Central venous-to-arterial carbon dioxide difference in critically ill pediatric patients with septic shock

To assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO₂] in evaluation of disease severity and prognosis in children with septic shock who already had central venous oxygen saturation (ScvO₂) higher than 70% after early resuscitation. In this prospective study, 48 septic shock children seen in Shanghai Children's Hospital, Shanghai Jiao Tong University were enrolled from Jun 2012 to May 2014. 36(75.0%) were male, 12 (25.0%) were female, the average age was (31.9 ± 24.5) months. The critically ill patients with septic shock were treated to achieve ScvO₂greater than 70% depending on early goal-directed therapy (EGDT). All patients were divided into two groups, based on P(cv-a)CO₂, low P(cv-a)CO₂group with P(cv-a)CO₂< 6 mmHg (1 mmHg = 0.133 kPa) and high P(cv-a)CO₂group with P(cv-a)CO₂≥ 6 mmHg. The parameters of hemodynamics including mean blood pressure (MAP), heart rate (HR), central venous pressure (CVP), perfusion-related parameters [ScvO₂, P(cv-a)CO₂, serum lactate (Lac), Lac clearance rate], pediatric critical illness score, PRISMIII score, and 28 days in-hospital mortality were recorded for all patients. Of the 48 cases with septic shock whose ScvO₂was higher than 70%, 17 patients (35.4%) had high P(cv-a)CO₂( ≥ 6 mmHg) and 31 (65.6%) had lower P(cv-a)CO₂(<6 mmHg). There were no significant differences between the 2 groups of patients in age, PRISMIII score and PCIS (P > 0.05 ), but Lac and P(cv-a)CO₂values were significantly different ( P < 0.05). Low P(cv-a) CO₂group patients had lower 28 days mortality than high P(cv-a) CO₂group[11/17 vs. 32.3% (10/31), P < 0.05]; 24 h after resuscitation, compared with high P(cv-a) CO₂group, low P(cv-a) CO₂group patients had lower Lac values [(2.0 ± 1.3) vs.( 2.7 ± 1.2) mmol/L, P < 0.05]. Low P(cv-a) CO₂group patients had shorter duration of vasoactive drugs use [(16 ± 14) vs. (44 ± 21)h, P < 0.05], 24 h Lac clearance rate was significantly higher for low P(cv-a) CO₂group than for high P(cv-a) CO₂group[ (31 ± 10) % vs. (26 ± 6)%, P < 0.05]. When ScvO₂> 70% was achieved after early resuscitation in septic shock children, P(cv-a) CO₂is a sensitive biomarker to assess tissue perfusion, and high P(cv-a) CO₂group patients had poor outcome.

Serum procalcitonin level in children with sepsis: clinical significance of its dynamic monitoring

Objective To research the diagnostic value of serum procalcitonin (PCT) for sepsis and bacterial infection in children, and evaluate the value of severity and prognosis evaluation by dynamic monitoring for PCT levels in children with sepsis. Methods Prospective study. From July 2011 to April 2012, 297 children in PICU were divided into sepsis group (n=125) and non-sepsis group (n=172). The sepsis group were divided into severe sepsis group and non-severe sepsis group, at same time, to be divided into bacterial sepsis group and non-bacterial sepsis group. The concentrations of serum PCT, C-reactive protein (CRP), WBC, neutrophil ratio in different time periods were obtained; the pediatric critical illness scores were conducted and sepsis related organ failure assessment were evaluated, the condition of prognosis was observed. Results The level of PCT in sepsis group and non-sepsis group were (21.31±18.27) ng/ml, (4.35±2.63) ng/ml, respectively. PCT of sepsis group was higher than that of non-sepsis group (t=4.744, P<0.01). The area under ROC curve of PCT, CRP and WBC in sepsis group were 0.737 (95%confidence interval: 0.633~0.840), 0.704 (95%confidence interval: 0.610~0.799), 0.666 (95%confidence interval: 0.554~0.778), respectively. When the level of PCT was 10 ng/ml, the diagnosis of severe sepsis had critical value, with sensitivity 80.2% and specificity 82.6%. We found that PCT rapidly increased at the early infection by dynamically observing PCT, CRP and WBC of sepsis group. Furthermore, when the infection was controlled after using the antibiotic for 5 days, PCT also quiekly came down. However, CRP, WBC remained high level after controlling the infection and they declined slower than PCT. The PCT level of the children in the dead group was significantly higher than that in the survival group. PCT showed negative correlation with pediatric critical illness score (r=-0.621, P<0.05), and positive correlation with sepsis related organ failure assessment (r=0.755, P<0.01). Conclusion PCT has important value for diagnosing severe sepsis and bacterial sepsis. Dynamic PCT monitoring is valuable in severity classification and prognosis assessment for critically ill children with sepsis, and provide guides for clinicians to adjust the antibiotic use in time. Key words: Sepsis; Procalcitonin; C-reactive protein

Polymorphism rs2239185 in vitamin D receptor gene is associated with severe community-acquired pneumonia of children in Chinese Han population: a case-control study.

Vitamin D receptor (VDR) is a potential candidate gene for community-acquired pneumonia (CAP). Examining the susceptibility VDR gene for CAP is essential for early intervention, prevention of related complications, and improvement of outcome. A case-control study was performed to examine the association between rs2239185 of VDR gene and CAP among children in Chinese Han population. Polymerase chain reaction and direct sequencing were used to genotype rs2239185 in 91 CAP children and 94 healthy children. For rs2239185, individuals with TT genotype showed a significantly higher risk of CAP than those with CC plus CT genotypes (P = 0.008). The occurrence of T allele of rs2239185 was significantly more frequent in CAP children than those in normal controls (P = 0.045).We found through stratification analysis that CAP children with systemic inflammatory response syndrome (SIRS), leukocyte count (WBC) >10 × 10(9)/L, C-reactive protein (CRP) >25 mg/L, procalcitonin (PCT) >2 ng/mL, and pediatric critical illness score <80 scores showed significantly higher frequency of TT genotype than those in normal controls (P = 0.0012, 0.0035, 0.0005, 0.0002, and 0.0021, respectively). TT genotype of rs2239185 in VDR gene might be one of the potential genetic risk factors for CAP, and T allele of rs2239185 might be associated with the susceptibility to CAP and the severity of CAP.

The change of P-selectin and E-selectin in critically ill children

Objective To study the changes of P-selectin and E-selectin in pediatric patients with critical illness ,and analyze their relationship with the severity and prognosis of diseases.Methods Forprospective study,42 critically ill patients admitted in pediatric intensive care unit （PICU ） from September,2012 to March,2013 as critically ill group were enrolled,and blood specimens were collected with 24 hours after admission.Another 42 cases blood samples were collected from children’s physical examination as control group.The severity of the critically ill patients were evaluated by Pediatric Critical illness Score （PICS）and Pediatric risk of score mortality （PRISM）-III.The levels of serum P-selectin and serum E-selectin were measured by double antibody sandwich enzyme-linked immunoassay （ABC-ELISA）. Results P-selectin and E-selectin in control group children and critically ill patients group were （37.23 ±8.99）ng/mL,（36.24 ±17.82）ng/mL,and （107.24 ±35.53）ng/mL,（114.93 ±40.17）ng/mL, respectively.There were statistical differences between two groups （P=0.000）.The levels of P-selectin and E-selectin in acute phase were higher than that of levels in recovery phase in critically ill group （P =0.000）.Negative correlation was observed between P-selectin concentration and the PCIS score （r =-0.673,P=0.000）,as well as E-selectin （r=-0.548,P=0.000）.P-selectin level and E-selectin level based upon PRISMⅢ≥10 group were significantly higher than they in PRISMⅢ 〈10 group （P=0.003,P=0.014）.In critically ill children,the differences in P-selectin,E-selectin were significant higher in death patients （P=0.003;P =0.000）.Compared with the non-sepsis illness group,the level of P-selectin and E-selectin in the severe sepsis patients were significantly higher （P =0.04,P =0.025 ）. Conclusions The levels of P-selectin and E-selectin are closely related to the severity and prognosis in critically ill children.Measuring the level of P-selectin and E-selectin could be used as a judegment the severity and to understand pathological physiological process. Key words: P-selectin; E-selectin; Critically ill; Child

ABSTRACT 885

Background and aims: To explore the relationship between blood lactate level and disease severity as well as prognosis in children with septic shock. Aims: To explore the relationship between blood lactate level and disease severity as well as prognosis in children with septic shock. Methods: From July 1, 2010 to June 30, 2012, 107 children with septic shock were treated in our pediatric intensive care unit (PICU), the clinical data were retrospectively collected and analyzed. Patients were divided into three groups on the basis of blood lactate level: normal lactate level (n=32), hyperlactatemia (n=31) and lactic acidosis (n=41). The percentage of compensated disease, pediatric critical illness score (PCIS), and prognosis were compared between three groups. Results: The percentage of patients with decompensated septic shock differed significantly between three groups (P<0.01). For patients with compensated septic shock, PCIS was significantly different between three groups (P <0.05). The same result was observed in patients with decompensated septic shock. The Spearman correlational analysis revealed an evident negative correlation between blood lactate level and PCIS (P=0.001). For patients with compensated septic shock, the cure and improvement rates in normal lactate level group (21.8% and 31.2%, respectively), and hyperlactatemia group (22.5% and 38.7%,respectively) were significantly higher than in the lactic acidosis group (0% and 12.2%, respectively). For patients with decompensated septic shock,, the mortality in lactic acidosis group (29.3%) was observably higher than in the normal lactate level group (0%), and hyperlactatemia group (9.7%), P<0.05. Conclusions: The blood lactate level correlated well with disease severity and prognosis in patients with septic shock.