Efficacy of continuous blood purification in treatment of severe acute pancreatitis in children / 中华儿科杂志

Objective@#To explore the therapeutic role of bedside continuous blood purification(CBP) in children with severe acute pancreatitis(SAP).@*Method@#The clinical and laboratory data of 11 children with SAP who were admitted to Pediatric Intensive Care Unit (PICU) of Shanghai Children′s Hospital from June 2013 to May 2016 were analyzed, including using pediatric critical illness score (PCIS) and pediatric risk of score mortality (PRISM)-Ⅲ score to assessing the severity of the disease.For those patients with severe organ dysfunction, CBP treatment was used when conventional therapy was not efficient.The evolution and prognosis of the disease were observed and analyzed.The measurement data were analyzed by Wilcoxon signed rank test.@*Result@#From June 2013 to May 2016, 11 cases with SAP were treated in PICU, of whom 7 cases had combined multiple organ dysfunction syndrome(MODS). After conservative treatment for 12-24 h, 6 cases with SAP deteriorated aggressively and were treated with CBP.PRISMA and PRISMA flex machines were used with Gambro PRISMA filter, and continuous venovenous hemodiafiltration(CVVHDF) or high volume hemofiltration (HVHF) were chosen as the therapy model.All 6 SAP patients survived after bedside CBP treatment(the median time spent on CBP were 48.5(48.0, 55.5) h). The serum concentration of amylase before and after the CBP treatment were respectively 675(495, 1 334)vs.176(136, 246) U/L, lipase 551(385, 1 075)vs.143(117, 185) U/L, CRP 168(125, 192) vs. 67(28, 87) mg/L, and inflammatory cytokines(TNF alpha 67.2(51.0, 72.9)vs. 22.6(19.3, 31.0) ng/L, IL-6 47.8(35.2, 88.4)vs. 23.6(20.3, 42.9) ng/L, IL-10 21.3(16.8, 23.9)vs. 35.6(26.5, 38.6) ng/L), which were obviously improved after CBP treatment(all P<0.05). And after CBP treatment, partial pressure of oxygen(PaO2)/fraction of inspiration O2(FiO2) (192(101, 208)and 240(207, 267) mmHg, 1 mmHg=0.133 kPa), MAP (58.3(56.3, 62.5) and 83.3(74.0, 87.4) mmHg) and PCIS scores (66(62.5, 72)and 92(89, 94) scores) were higher (all P<0.05).@*Conclusion@#CBP in critically ill with SAP can rapidly reduce blood amylase and lipase, help to keep the stable internal environment, block the systemic inflammatory response, improve the organ functions and maintain the fluid balance.CBP treatment may be a potential therapy in children with SAP.

Noninvasive pulmonary arterial pressure monitoring in the children with severe pneumonia and respiratory failures and its significance / 中华实用儿科临床杂志

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 pediatric critical illness score(PICS) was 70.5 ± 9.6,and the pediatric risk of score m ortality Ⅲ 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(x2 =15.78,P ＜0.0l ; x2 =5.18,P ＜ 0.05).The mechanical ventilation time was longer in pulmonary arterial hypertension group (t =3.89,P ＜0.01).PAP was (58.23 ±5.44) mmHg(1 mmHg =0.133 kPa),(49.10 ±4.69) mmHg,(42.53 ±4.54)mmHg and(35.63 ±4.78) mmHg respectively before and after using Milrinone 24 h,48 h and 72 h in 46 cases with pulmonary arterial hypertension,and the pressure decreased significantly after using medicine (F =67.11,P ＜ 0.01).There was no significant difference in CI,LVEF and E/A(all 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.

Effects of microRNA-155 on interleukin-1 receptor-associated kinase 1 and 4 mRNA expression in liver injury of endotoximia mice / 中国小儿急救医学

Objective To explore the protective effect of rnicroRNA (miRNA)-155 inhibitor on interleukin-1 receptor-associated kinase (IRAK)-1 mRNA and IRAK-4 mRNA in endotoximia induced liver injury in mice.Methods One hundred and twenty male BALB/c mice were randomly divided into healthy control group(n =40),endotoximia group (n =40) and miRNA-155 inhibitor group (n =40).Each group were divided into 6 h,12 h,24 h,48 h subgroups,each of which consisted of 10 mice.The mice in miRNA-155 inhibitor group were administered with miRNA-155 inhibitor[80 mg(kg ·d)] via tail vein injection before lipopolysaccharide (LPS) administration while the other two groups treated with normal saline,following 24 hours,model of endotoximia mice was produced by injection of LPS intraperitoneally.At 6 h,12 h,24 h,48 h after LPS exposure,the experimental mice were sacrificed and the liver tissue samples were collected.Histopathological changes,the expression of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,tumor necrosis factor (TNF)-α,IL-1,IL-10 were detected.Results LPS exposure resulted in increase of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,TNF-α,IL-1 and IL-10 in both endotoximia group and miRNA-155 inhibitor group compared to the control group,miRNA-155 inhibitor resulted in decrease of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,TNF-α,IL-1 and IL-10 in miRNA-155 inhibitor group compared to the endotoximia group.There were significant differences of miRNA-155 expression at 12 h,24 h,48 h after LPS exposure among 3 groups (P ＜ 0.05).Both IRAK-1 mRNA and IRAK-4 mRNA showed significant differences at 12 h,24 h,48 h.Turning to inflammation factors,differences were found among 3 groups at all time points (P ＜ 0.05).At light-scope,there was improvement in sepsis associated liver injury in miRNA-155 inhibitor group compared to endotoximia group.Conclusion miRNA-155 inhibitor administration appears to down regulate IRAK-1 mRNA and IRAK-4 mRNA expression and further deduce the excessive inflammatory and anti-inflammatory reaction,which may alleviate liver injury in endotoximia mice.

Central venous-to-arterial carbon dioxide difference in critically ill pediatric patients with septic shock / 中华儿科杂志

<p><b>OBJECTIVE</b>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.</p><p><b>METHOD</b>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.</p><p><b>RESULT</b>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].</p><p><b>CONCLUSION</b>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.</p>

Clinical features and diagnosis of severe tuberculosis infection in PICU / 中国小儿急救医学

Objective To explore the clinical features and diagnostic methods of tuberculosis infection in PICU,and improve the understanding of tuberculosis.Methods We analysed the clinical features and diagnostic methods of severe tubercle bacillus infectious diseases in PICU from Jan 2009 to Dec 2012.Severity of disease was graded by pediatric critical illness score.The diagnosis of the pulmonary tuberculosis was in accord with the diagnostic criteria of paediatric pulmonary tuberculosis established by Chinese Medical Association paediatrics branch.And the diagnosis of tuberculosis meningitis and tuberculosis peritonitis based on the clinical physical examination,laboratory examination and pathologic finding.Results Among 22 cases enrolled in this study,totally 16 cases were pulmonary tuberculosis,6 cases were extrapulmonary tuberculosis,and 3 cases were tuberculosis meningitis.The clinical feature of severe tuberculosis infection in PICU was accompanying with one or multiple organ dysfunction besides tuberculosis infection symptom,among them,respiratory dysfunction occurred in 16 cases,cardiovascular dysfunction was observed in 2 cases,and central nervous system dysfunction was found in 3 cases,even 1 patient experienced cardiovascular system dysfunction,respiratory disorder as well as gastrointestinal system dysfunction simultaneously.Sixteen cases of pulmonary tubercle bacillus infection manifested respiratory failure besides fever,cough,shortness of breath and tuberculosis toxicosis symptom,2 cases of them developed into acute respiratory distress syndrome,8 cases needed mechanical ventilation.Two cases of pericardial effusion presented cardiac tamponade.The level of adenosine deaminase elevated in 12 cases,and the positive result of enzyme-linked immunospot assay for tubercle bacillius was observed in 14 cases.Conclusion It is very important to be aware of that severe tubercle bacillus infection exist in critically ill patients admitted in PICU,measuring the level of adenosine deaminase and taking enzyme-linked immunospot assay for tubercle bacillius test are important accessory examination for tuberculosis diagnosis in children.

Corticosteroids treatment in acute respiratory distress syndrome / 中国小儿急救医学

The presence and persistence of systemic and lung inflammation in children with acute respiratory distress syndrome (ARDS) is the basis for the use of corticosteroids as a therapeutic agent.The trial of ARDS treated with high-dose short-course corticosteroids showed no benefit,even increase motality.At present,the results of randomized controlled trial and meta-analysis suggested that low-dose and replacement-dose methylprednisolone [1-2 mg/(kg· d)] or equivalent types of corticosteroids may decrease the fatality rate,reduce staying days in ICU and the duration of mechanical ventilation.Use of corticosteroids for ARDS in children is still lack of multicenter randomized controlled trial.

The significance of urine neutrophil gelatinase-associated lipocalin as an early diagnostic marker in critical ill children with acute kidney injury / 中国小儿急救医学

Objective To evaluate the value of urine neutrophil gelatinase-associated lipocalin (uNGAL) to early diagnose acute kidney injury(AKI) of critically ill children in PICU.Methods Eighty critically ill children at PICU of Children's Hospital Affiliated to Shanghai Jiaotong University were enrolled in this study from April to June 2013.They were continuously observed for 72 hours.According to pediatric RIFLE criteria for diagnosis of AKI,patients were divided into AKI group (15 cases) or non-AKI group (65 cases).Additionally,according to sepsis diagnostic criteria,patients were divided into sepsis group (31 cases) or non-sepsis group (49 cases).The levels of serum creatinine and uNGAL were measured within 6th hour,24th hour,48th hour,72th hour after admitted to PICU.The differences of uNGAL levels between AKI and non-AKI groups,sepsis without AKI and non-sepsis non-AKI groups,sepsis merged AKI and sepsis without AKI groups were analysed.The sensitivity and specificity of uNGAL and serum creatinine for diagnosis of AKI at 48th hour were evaluated by ROC curve.Results Thirteen cases of eighty children developed to AKI after admitted to PICU.(1)The uNGAL levels [M(QR),ng/ml] in AKI group within 6th hour,at 24th hour,48th hour,72th hour were 863.00 (696.00),700.50 (580.00),365.50 (285.00),289.50 (319.30),respectively,which were significantly higher than those in non-AKI group [20.00 (106.00),20.00 (85.30),20.00(101.00),20.00(36.00)] (P ＜0.01).(2)The uNGAL levels in new developed group were much higher than those in non-AKI group at each time point.The comparision of serum creatinine at 48th hour was statistic difference.(3)The uNGAL levels rised at early stage in sepsis without AKI group and down to normal gradually after 48th hour.(4)The uNGAL levels continued increasing in sepsis merged AKI group,and had significant differences comparing with sepsis without AKI group(P ＜ 0.01).(5) The areas under ROC curve of uNGAL and serum creatinine at 48th hour were 0.902(95％ CI:0.801 ～ 1.004) and 0.801 (95％ CI:0.768 ～ 0.981),respectively.Conclusion The level of uNGAL has earlier increase for 24 to 48 hours than that of serum creatinine in critically ill children,and it can also reflect the severity of AKI.Therefore it can be used as an early diagnostic biomarker for AKI in PICU.

Changes of epithelial neutrophil activating peptide-78 in critically sick children and its significances / 中华实用儿科临床杂志

Objective To investigate the changes of epithelial neutrophil activating peptide-78 (ENA-78) in the serum of patients with critical illness,and to analyze the relationship between the severity and prognosis.Methods Prospective case-control study was performed,and 42 cases of critically ill patients admitted to Pediatric Intensive Care Unit,Children's Hospital Affiliated to Shanghai Jiaotong University from Sep.to Nov.2013 were selected as critically ill group,blood specimens were collected within 24 hours and 7 days after their admission.Another 42 cases of blood samples were collected during physical examinations in this hospital as control group.The severity of critically ill patients were graded by Pediatric Critical Illness Score (PICS) and Pediatric Risk of Score Mortality (PRISM) Ⅲ,and the serum ENA-78 was measured by double antibody sandwich enzyme-linked immunoassay.Results 1.The level of ENA-78 in the control group was (0.44 ± 0.28) ng/L; ENA-78 in acute phase and recovery phase of critically ill group were (2.85 ± 0.89)ng/L and (1.00 ± 0.64)ng/L,respectively,there were statistical differences between control group and critically ill group,acute phase group and recovery phase group (all P =0.000).2.The negative correlation was observed between ENA-78 concentration and PCIS score(r =-0.724,P =0.000).ENA-78 in PRISM Ⅲ ≥ 10 group was significantly higher than that in PRISM Ⅲ＜ 10 group(P =0.000).The ENA-78 between death group and the survival group was significantly different(P =0.000).3.ENA-78 in patients with severe infection was higher than that in the non-infectious cases(P =0.000).4.With the organ dysfunction expanded ENA-78 rose accordingly,and the difference was statistically significant (P =0.000).Conclusions The level of ENA-78 is different in critically ill patients in children.It can provide reference of assessing the severity of disease and predicting prognosis by determing the ENA-78 level.

The change of P-selectin and E- selectin in critically ill children / 中华急诊医学杂志

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.

Comparison of clinical characteristics of severe pertussis and pertussis-like syndrome in children / 中华实用儿科临床杂志

Objective To explore the clinical characteristics and management of children who were critically ill with severe pertussis and those who had severe pertussis-like syndrome.Methods The patients with severe pertussis and severe pertussis-like syndrome admitted to Pediatric Intensive Care Unit from Mar.2005 to Mar.2013 were involved in this study,and their clinical characteristics were collected and the experience of management was summarized.Resuits Totally 31 patients were involved in the study,15 cases were male and 16 cases were female,the median age was 2.68 months (age ranged 34 days-7 months).All the 16 cases of severe pertussis were less than 3 months,and none of them had received pertussis vaccine.Of 31 patients,16 (51.61％) cases were characterized by apnea,12 (38.70％) cases showed cyanosis,10(32.26％) cases exhibited bradycardia,8(25.80％) cases presented spasmodic cough,leukocytosis [white blood cell count (26.85 ± 12.43) × 109/L] as well as lymphocytosis [blood lymphocyte (70.10 ± 8.82)％] were observed.Complications included respiratory failure(13 cases,41.94％),pulmonary hypertension (7 cases,22.58％),circulatory dysfunction(6 cases,19.35％) and encephalopathy(5 cases,16.13％).Two cases of severe pertussis patients presenting with cardiac arrest received CPR survival due to prolonged apnea.Severe pertussis infants were more likely to present apnea,cyanosis,bradycardia and be complicated with pulmonary hypertension than those who had severe pertussis-like syndrome infants [75.00％ (12/16 cases) vs 26.70％ (4/15 cases),x2 =7.008,P=0.008;62.50％ (10/16 cases) vs 13.30％ (2/15 cases),x2 =7.634,P =0.006;50.00％ (8/16 cases) vs 13.30％(2/15 cases),x2 =4.610,P =0.032;37.50％ (6/16 cases) vs 6.67％ (1/15 cases),x2 =4.074,P =0.044].In the patients with pulmonary hypertension group,the white blood cell count,the rate of suffering from respiratory failure as well as circulatory dysfunction,the rate of using mechanical ventilation,the rate of using vasoactive drug were significantly higher than those in the normal pulmonary arterial pressure group[(47.96 ± 17.79) × 109/L vs (23.20 ± 5.29) x 109/L,t =2.278,P =0.025 ; 71.42％ (5/7 cases) vs 8.33 ％ (2/24 cases),x2 =11.943,P =0.001 ;71.42％ (5/7 cases) vs 8.33％ (2/24 cases),x2 =11.943,P =0.001 ;42.86％ (3/7 cases)vs 0 (0 case),x2 =11.020,P =0.001 ;42.86％ (3/7 cases) vs 0 (0 case),x2 =11.020,P =0.001].Pertussis-mediated pulmonary hypertension were also treated with milrinone,and all cases were cured.Conclusions Severe pertussis and severe pertussis-like syndrome in infants are characterized by high morbidity of apnea and respiratory failure.Severe pertussis tends to occur in younger unvaccinated infants(＜3 months).Severe pertussis is more likely to be combined with pulmonary hypertension.Pulmonary hypertension is the sign of disease get aggravation,and milrinone treatment may be effective.

Continuous hemodialysis/hemofiltration for treatment of the critical hemophagocytic syndrome in children / 中华急诊医学杂志

Objective To study critical hemophagocytic syndrome (HPS) or macrophage activation syndrome (MAS) presented with multiple organ dysfunction syndrome (MODS) in pediatric intensive care unit (PICU),including clinical features and outcomes In order to explore the effect of bedside continuous hemodialysis/hemofiltration (CBP) as adjuvant treatment for severe HPS/MAS.Methods A total of 19 children with HPS/MAS were hospitalized met the diagnostic criteria for HPS from January,2009 to December,2012.Twelve cases were treated with CBP by continuous venin-venin hemodialysis/hemofiltration (CVVHDF) or high-volume hemofiltration (HVHF) following conventional anti-inflammatory therapy.The replacement liquid dose was 50-75 ml/ (kg · h).The organs function were evaluated and laboratory biomarkers including blood 、electrolytes,ferritin changes were measured before and after CBP treatment.Results Ninteen cases of HPS were acute onset and developed to MODS rapidiy after admission to PICU.The main clinical features were the irregular fever or high fever,hepatosplenomegaly and significant liver damage,nervous system dysfunction and disseminated intravascular coagulation (DIC).Eight cases were death and mortality rate was 42.1％,and all death occurred in those aged less than 3 years old.The mortality rate were 25％ (3/12) and 71.4％ (5/7) in CBP group and non-CBP group respectively.After CBP for 6-24 hours,the fever returned to normal range and blood electrolytes improved.The serum ferritin,serum alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) reduced significantly.Serum creatinine (sCr),blood urea nitrogen (BUN) level improved.Four cases with acute respiratory distress syndrome (ARDS) improved and the ventilator parameters were downregulated.Conclusions Our findings indicate that HPS/MAS complicated with MODS is life threatening with high mortality rate.CBP therapy can lower the fever within a short time,correct electrolyte imbalance,stable circulatory function,improve the lung,liver,and brain function.It is suggested that CBP may be the potential effective therapy in severe HPS/MAS with MODS in children.

Vasoactive intestinal peptide and methylprednisolone change intestinal Toll-like receptor mRNA expression in rats with endotoxic shock / 中国小儿急救医学

Objective To investigate the effect of vasoactive intestinal peptide (VIP) and methylprednisolone (MP) on Toll-like receptor (TLR)2/4 mRNA expression in endotoxin (lipopolysaccharide,LPS) induced shock.Methods Ninety Sprague-Dawley rats were randomly divided into LPS group (n =20),LPS + VIP group (n =20),LPS + MP group (n =20),LPS + VIP + MP group (n =20) and control group (n =10).LPS group injected intravenously LPS (E Coli O55B5) 10 mg/kg.LPS + VIP group,LPS + MP group and LPS + VIP + MP group were injected intravenously VIP 5 nmol/kg,MP 3 mg/kg and VIP 5 nmoL/kg + MP 3 mg/kg after LPS 10 mg/kg injection.The control group injected normal saline intravenously instead of LPS.The rats were sacrificed at 6 h and 24 h after injection and the intestine samples were collected.Pathological changes of the intestine were observed by microscopy.RT-PCR was used to detect the intestinal TLR2 mRNA and TLR4 mRNA expressions.Results Intestinal mucosa showed edema or necrotic change with structure of the microvilli disappeared after LPS injection.The inestinal lesions in VIP,MP and VIP + MP groups were milder than LPS group.At 6 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions were significantly up-regulated in LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:1.14 ±0.38,1.17 ±0.42,1.16 ±0.41,0.92 ± 0.29;TLR4 mRNA 1.21 ±0.18,1.04 ± 0.38,1.11 ± 0.34,1.01 ± 0.20) compared with the control group (0.32 ± 0.20,0.24 ± 0.17) (P ＜ 0.01).But there was no significant difference between LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (P ＞ 0.05).At 24 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions in LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:0.63 ± 0.12,0.59 ± 0.13,0.52 ±0.19;TLR4 mRNA 0.67 ±0.09,0.64 ±0.09,0.51 ±0.13) were significantly lower than LPS group (1.04 ± 0.38,0.82 ±0.18) (P ＜0.01) (P ＜0.05).Conclusion VIP and/or MP can mitigate intestinal injury induced by LPS shock.The gastrointestinal protection of VIP and glucocorticoids were related to downregulation signaling TLR2 mRNA and TLR4 mRNA expression.But VIP/MP and VIP + MP have no significant effect on expression of intestinal TLR2/4 mRNA until 24 h after LPS shock.

Continuous veno-venous hemodiafiltration on acute kidney injury in children / 中国小儿急救医学

ObjectiveTo investigate the effect and outcome of critically illness with acute kidney injury (AKI) treated with continuous veno-venous hemodiafiltration (CVVHDF) in children.Methods Twenty-four cases of critically illness with AKI were treated with CVVHDF in our pediatric intensive care unit from Jan 2008 to Dec 2010.The levels of creatinine (Cr),blood urea nitrogen (BUN),K +,Na + and HCO3- were observed before CVVHDF and 6,12,24,48,72 h after CVVHDF.ResultsCatheter was successfully established for CVVHDF in 24 cases of AKI.The average duration of CVVHDF was 46 h ( 16 ～142 h).The blood levels of Cr and BUN were significantly decreased at 6 h after CVVHDF [ ( 196.3 ±112.4) μmol/L,( 13.3 ± 8.5 ) mmol/L] and 12 h after CVVHDF [ ( 106.1 ± 84.2) μ mol/L,( 10.2 ± 9.7 )mmol/L] as compared to those before treatment [ (340.6 ±298.2) μmol/L,(31.6 ± 11.3) mmol/L] (P ＜0.05,P ＜ 0.01 ).After 48 h of CVVHDF,the Cr,BUN returned to normal range.The imbalance of blood K +,Na +,and HCO3- improved at 6 h after CVVHDF and returned to nomal levels at 24 h.Total 28 d fatality rate was 29.2％ (7/24),and all death cases were complicated with multiple organ dysfunction syndrome.ConclusionCVVHDF therapy for AKI can quickly clear Cr,BUN and excess water,correct electrolyte disorders,improve kidney function in children.

Individualized monitoring and treatment for children with severe enterovirus 71 infection of different stages / 中国小儿急救医学

Objective To investigate the clinicalmanifestation,monitoring and therapeutic measure of severe enterovirus 71 ( EV71 ) infection in children.MethodsForty-five cases of severe EV71 infectionwere admitted in our PICU from May 2010 to Sep 2011.The vital sign and arterial blood pressure,central venous pressure,mixed venous oxygen saturation,dynamic non-invasive heart function and urine volume were monitored.Forty-five cases were divided into 3 stages according to clinical manifestation:( 1 ) nervous system involvement stage; (2) respiratory system involvement stage; ( 3 ) circulatory system involvement stage ( compensation and decompensation).We adopted individualized remedy measure according to different stages.ResultsIn 45 cases,38 cases discharged from hospital,the cure rate was 84.4％.Among all the 38 cases,nervous system involvement was found in 19 cases,respiratory system involvement was found in 12 cases,circulatory system involvement was found in 7 cases.Seven cases died,who had circulation failure.ConclusionWe should identify severe EV71 infection early.Positive control of high fever,appropriate liquid treatment,control of high blood pressure,early respiratory support,preventment of circulation failure are the key measures for treatment.Individualized monitoring and treatment are effective in children with severe EV71 infection.

Adrenal insufficiency evaluation by using Iow-dose ACTH stimulation test in critical illness children / 中华急诊医学杂志

Objective To evaluate the validity of original plasma cortisol level and responses to lowdose ACTH stimulation test in assessing the severity of critical illness.Method Original level of cortisol and cortisol concentrations 30 min after administration of a low dose ( 1 μg/1.73m2 ) of cosyntropin were determined within 24 hours after admission to our PICU.Critical illness related cortisol insufficiency was defined by initial level of cortisol ＜ 10 μg/dL or an increment cortisol [ Δmax =Stimulated plasma cortisol level (T1) -initial cortisol level (T0)]≤ 9 μg/dL.Results Ninety-five consecutive patients were admitted to PICU from May 2010 to April 2011.The patients were assigned to severe sepsis group (35/95),major operation group (30/95),and other critical illness group (30/95).Overall mortality was 12.6％ (12/95).The initial and stimulated plasma cortisol levels in three groups were (37.17 ± 47.35 ) μg/dL,(31.52±52.78) μg/dL,(28.61 ±17.45) μg/dL,vs.(50.26±48.21) μg/dL,(58.56±73.21)μg/dL, (42.41 ± 13.56) μg/dL,respectively.There were no significantly differences between above groups ( P ＞ 0.05 ).The incidence of critical illness-related corticosteroid insufficiency (CIRCI) in this study was 55.8％.The incidences of CIRCI were 60％,53.3％,and 53.3％ in severe sepsis,other critical illness and major surgery illness,respectively ( P ＞ 0.05 ).The morbidity of CIRCI and normal response group were 7.5％ and 19％ (P ＞0.05).The levels of T0 and T1 were related to the PCIS (P ＜0.05). Conclusions CIRCI is often seen in children with critical illness. And a low-dose ACTH stimulation test can be used to evaluate the adrenal function in critical illness.However,there is no significant correlation between CIRCI and mortality of critically ill children in this study.

Clinical characteristics and antibiotics resistance of pseudomonas aeruginosa infection in pediatric intensive care unit / 中国小儿急救医学

Objective To explore the clinical characteristics of critically ill children infected with pseudomonas aeruginosa(PA) and PA antibiotics resistance in pediatric intensive care unit (PICU).Methods Case records of children with PA infection admitted to PICU in children′s hospital affiliated to Shanghai Jiaotong University from Jan 2007 to Dec 2009 were reviewed for clinical characteristics,case fatality rate,prognosis and drug resistance.Results (1) Clinical features:12 cases were community-acquired infection and 46 cases were hospital-acquired infections in 58 cases.On the same period,hospital-wide surveillance obtained PA 232 strains,PICU obtained PA 112,the ratio was 48.3%.Twelve cases died and total mortality was 20.7%.The mortality was significantly difference between community-acquired infections (5 cases,41.6%)and hospital-acquired infections (7 cases,15.2%)(P<0.05).The main symptom of children with community-acquired infections were intestinal infection (5 cases) and sepsis (5 cases).The children had acute onset and developed to shock and multiple organ dysfunction syndrome rapidly.Laboratory examination revealed the white blood cell normal (7/12) and decreased in 5 cases (5/12).The value of C-reactive protein was increased significantly,and the concentration of blood endotoxin were also increased.In the hospital-acquired PA infection cases,the main symptom was respiratory abnormal (38 cases),worsen primary disease,extended staying days in PICU.(2)Drug resistance analysis:112 PA,69.8% of ceftazidime-resistant,72.8% of the imipenem-resistant.Conclusion There is significant difference of the clinical features between PA community-acquired infection and hospital-acquired infection.The former is mostly primary infections with high fatality rate.PA hospital-acquired infection has become an important pathogen of nosocomial infection in PICU.And it is important to prevent PA infection caused by a long term broad-spectrum antibiotics application and invasive medical procedures.

The clinical study of CD64 in infected children treated in ICU of Shanghai Children Hospital / 中华急诊医学杂志

Objective To evaluate the values of CD64 expression in diagnosis of infected patients referred to intensive care unit.Method Sixty febrile children referred to the hospital intensive care unit from 2009.11 to 2010.03 were enrolled for a retrospective study.Fever was defined as a body temperature reaching 38℃ or higher with specifically bacterial infection or highly suspected with bacterial infection or viral infection.There were 28 patients with bacterial infection and 32 with viral infection.The non-infectious diseases such as juvenile rheumatoid arthritis and Kawasaki disease were excluded.The controls were 50 healthy children asking for physical examination.On admission,CD64 were measured by using flow cytometry,and blood routine examination,ESR,PCT,blood cultures and sputum cultures were simultaneously detected in all febrile patients.Data were statistically analyzed by using SAS 16.0 software.Data are given as means±SE.Categorical variables were analyzed using X2 test and continuous variables were compared by applying paired 1-tailed t test,Significance level was set at less than 0.05.Results of them,57.1%bacterial infection patients and 71.9%viral infection patients contracted pneumonia.CD64 in bacterial infection patients、viral infection patients and the subjects of control group were(12.6±9.7),(5.4±2.42)and (2.9±0.77),respectively.The CD64 in the bacterial infection patients were significantly higher than those in the virus infection patients(F=11.002,P=0.004).Conclusions CD64 in infected children referred to a hospital intensive care unit can be clearly distinguished between bacterial infections and viral infections, providing an important guidance and a flexible strategy for clinical treatment and determine the timing of withdrawal.

Risk factors for invasive fungal infection in pediatric intensive care unit / 中国小儿急救医学

Objective To analyze the incidence,clinical feature and the risk factors of invasive fungal infection in pediatric intensive care unit (PICU). Methods We retrospectively summaried the invasive fungal infection in our PICU from Jan 2007 to Dec 2009 in order to analyze the incidence, clinical feature and the risk factors of invasive fungal infection in PICU. Multiple clinical data were collected such as pediatric critical illness score, mechanical ventilation, urinary drainage tube, indwelling gastric canal and continuous blood purification. Results ( 1 ) The incidence rate of invasive fungal infection was 1.65 % ( 35/2 116 ). The morbidity was 20. 00% ( 7/35 ). ( 2 ) Mean infected day was ( 10. 4 ±- 8. 3 ) d after admission. The clinical manifestations included fungal pneumonia( 60. 0% ), peritonitis ( 14. 3% ), urinary tract infection ( 11.4% ),intestinal tract infection(8. 6% ) ,sepsis(2. 9% ) and meningitis(2. 9% ). All of the patients had used broad spectrum antibiotic. (3) The risk factors of invasive fungal infection included lower pediatric critical illness score, mechanical ventilation, indwelling gastric tube, urinary drainage tube and continuous blood purification.(4) Candia albicans was the predominant pathogen in invasive fungal infection. Conclusion Invasive fungal infection has become one of the main nosocomial infection in PICU. Lung is most commonly involved and candida albicans is the major pathogen. Using antibiotics appropriately, decreasing unnecessary invasive performance,and rationally using antifungal agent mi.ght be effective strategy for invasive fungal infection in PICU.

Clinical characteristics of influenza A caused by H1N1 virus strain in critical children with acute respiratory distress syndrome and emergency treatment / 中华急诊医学杂志

Objective To describe the characteristics of and emergency treatment for and outcomes of critical ill children with 2009 influenza A caused by H1N1 virus strain. Method A prospective observational study of 3 pediatric patients with severe influenza A of H1N1 virus strain complicated with acute respiratory distress syndrome (ARDS) from November to December 2009. Results The H1N1 virus strain was confirmed by using realtime reverse transcription polymerase chain reaction (Real-time RT-PCR). Two patients survived and one died. Fever and cough were the onset symptoms. The systemic responses to influenza A at first were relatively mild. The tragic deterioration occurred all of a sudden with cyanosis all over the lips and dyspnea. The roentgenography showed bilateral multiple tabular pulmonary effusion and diffuse opaque shadows. The length of time required to confirm the diagnosis of ARDS from the symptom onset was 4 to 6 days. All patients were severely hypoxic with the ratio of PaO2 to 0.7-0.9 fraction of inspired oxygen (FiO2) to be 70- 100 mmHg at admission to PICU. In order to avoid injury to the lung, the protective ventilation strategy was carried out with low tidal volume (6 mL/kg) and adequate pressure,and conservative fluid management. Conclusions The H1N1 strain influenza virus A is characterized by pyrexia, cough and other respiratory symptoms in the early stage of critically ill children. In a few days, cough increased along with a sudden burst of cyanotic lips and shortness of breath, highly suggesting ARDS. Timely oxygen therapy and respiratory support, conservative fluid management, and the prophylaxis of secondary infection may be the essential measures. More clinical data are needed to clarify the critical features and to evaluate the emergency therapy for H1N1 influenza A in critically ill children.

A Comparison Study of Using Sildenafil on Persistent Pulmonary Hypertension of the Newborn / 临床儿科杂志

Objective To investigate the effect and safety of sildenafil on persistent pulmonary hypertension of the newborn (PPHN). Also compared the effect of sildenafil with tolazoline and milrione. Methods Forty five neonates with PPHN were recruited from January 2005 through October 2008 in NICU, 25 males and 20 females. The median gestational age was (39.3 + 2.4) weeks, the median birthweight was (3 114.0±10.2) g, and the median age were (13.0±0.8) hours. The patients were randomly assigned to receive sildenafil, tolazoline and milrione therapy. The pulmonary artery pressure (PAP) was measured by echocardiography. Results Thirty patients were cured, 6 patients were improved and 9 patients were of no effect. The total effective rate was 80%. There was no statistical difference among sildenafil, tolazoline and milrione. The PAP decreased when the patients were treated with sildenafil, tolazoline and milrione. No side effects happened in all patients treated with the three drugs. Conclusions Sildenafil is an effective and safe drug to reduce PAP of PPHN and it also help to improve cardiac function.