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Sepsis is a common critical illness in PICU, with high morbidity and mortality.As the pathogenesis is still not well defined, the clinical management of sepsis can be tricky.The gastrointestinal tract is currently considered as one of the most susceptible organs in the early stages of sepsis, and intestinal microecology plays important roles in the development, progression and prognosis of this disease.There is a closely relationship between intestinal flora dysbiosis/translocation and sepsis.They interact with each other, and ultimately leading to multi-organ dysfunction.In this review, we provided a brief summary of intestinal microecological changes and its pathogenesis in sepsis, as well as the progress of treatment.
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Objective:To explore the clinical features and the mortality risk factors of hemophagocytic lymphohistiocytosis (HLH) in pediatric intensive care unit (PICU).Methods:Clinical data of 68 children diagnosed as HLH and treated in PICU, the Children′s Hospital, Zhejiang University School of Medicine between January 2014 and December 2020 were retrospectively analyzed.According to the lowest pediatric critical illness score (PCIS) within 24 h after admission to PICU, they were divided into non-critical group, critical group and extremely critical group.Moreover, they were further divided into survivors and non-survivors based on the prognosis.Clinical characteristics in each group were analyzed and compared. Logistic regression analysis was performed to obtain the estimates of odds ratio ( OR) and corresponding 95% confidence interval ( CI) of possible predictive factors for death. Results:The median age of recruited 68 children with HLH and treated in PICU was 26 months, involving 39 female and 29 male patients.The overall mortality rate was 45.59%(31/68 cases). Epstein-Barr virus (EBV) infection was the major cause of HLH.The mortality of non-critical group, critical group and extremely critical group were 21.05% (8/38 cases), 57.14% (8/14 cases) and 93.75% (15/16 cases), the difference was statistically significant ( P<0.05). The PCIS, the pediatric logistic organ dysfunction score 2 (PELOD-2), duration of fever, mechanical ventilation within 6 h, vasoactive use, gastrointestinal and pulmonary hemorrhage, disseminated intravascular coagulation (DIC), hepatobiliary dysfunction (HBD) and acute kidney injury (AKI), acidosis[pH and base excess (BE)], hemoglobin (Hb), prothrombin time (PT), and activated partial thromboplastin time (APTT), serum creatinine (Scr), interleukin-6 (IL-6) were significantly different between survivors and non-survivors (all P<0.05). The Logistic regression analysis showed that PCIS ( OR=0.800, 95% CI: 0.707-0.905, P<0.001), Hb ( OR=0.929, 95% CI: 0.871-0.991, P=0.027), APTT ( OR=0.954, 95% CI: 0.910-0.990, P=0.047), and AKI( OR=29.064, 95% CI: 3.072-274.957, P=0.003) were risk factors for the death of HLH. Conclusions:HLH has a very high mortality and requires critical care in PICU, low PCIS, anemia, prolonged APTT and AKI are independent risk factors for the death of HLH.
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Objective:To investigate pediatric sepsis-related mortality of pediatric intensive care unit(PICU) and family socioeconomic status in Yangtze River Delta.Methods:A prospective, multicenter observational study was conducted to collect sepsis cases from eight PICUs in Jiangsu, Zhejiang and Shanghai from August 2016 to July 2017.Sepsis cases were divided into normal sepsis group and severe sepsis group.The primary outcome was in-hospital death.Patient data were prospectively collected including age, gender, medical insurance status, long-term residence, source of admission, first-day pediatric sequential organ failure score(pSOFA) score, underlying diseases and socioeconomic characteristics including family education level, family annual economic income.Results:A total of 4, 983 patients admitted in PICUs, of which 651 patients were diagnosed sepsis on admission.The prevalence of sepsis was 13.1% (651/4 983), and overall mortality was 11.7% (76/651). The prevalence of severe sepsis was 28.3% (184/651), and the mortality was 20.1% (37/184). The overall median age was 0.9 years old.The infant group accounted for 50.8%, including 331 cases, followed by toddler group 19.8% (129 cases), preschool group 13.0% (86 cases), school group 11.8% (77 cases), and adolescent group 4.3% (28 cases). The median pSOFA score was 4.Logistic regression analysis showed that the OR value was 1.4(95% CI 1.3-1.5) of pSOFA score corresponding to the death of sepsis in hospital.There were 14.6% patients left hospital in medical insurance group, while 27.4% in non-medical insurance group, and there was significant difference between these two groups.The median of daily cost was 5, 446 RMB, among which the median of daily cost of sever sepsis was 6, 678 RMB.The median of total cost for sepsis was 36, 109 RMB, and that for severe sepsis was 41, 433 RMB. Conclusion:The sepsis-related mortality was high in PICU.The pSOFA score has a certain predictive value for the prognosis of sepsis.The burden of sepsis is still heavy.Compared with medical insurance families, non-medical insurance families have a higher proportion of choosing left hospital.
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Purulent pericarditis is still a life-threatening disease for children.Utilizing antibiotics and performing completely drainage of pus are the major treatment options.Constrictive pericarditis is an important complication of purulent pericarditis.Intrapericardial fibrinolysis can effectively reduce fibrin deposition in pericardium, prevent pericardium adhesion and fibrosis, therefore it will prevent constrictive pericarditis.However, it is seldom used in the treatment of children with purulent pericarditis.This article reviews the domestic and international reports on intrapericardial fibrinolysis in children with purulent pericarditis, introduces the indications, mechanisms, treatment protocols, effectiveness studies and complications of intrapericardial fibrinolysis, thus providing a reference for the treatment protocol of children with purulent pericarditis.
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Objective@#To explore the effect of valproic acid with different loading doses in treatment of children with status epilepticus.@*Methods@#The data of children who were hospitalized in the intensive care unit of the Children′s Hospital Affiliated to Zhejiang University because of status epilepticus from January 1, 2013 to December 31, 2017 were collected.All the patients were divided into different groups according to loading dose of valproic acid.The effect were analyzed in different groups.@*Results@#(1)There were 66 children with status epilepticus were admitted, including 35 males and 31 females.Among all children with status epilepticus, the etiology included epilepsy(n=36, 54.5%), intracranial infection(n=16, 24.2%), hypoxic asphyxia (n=3, 4.5%), intracranial tumor(n=2, 3.0%), abnormal brain development(n=2, 3.0%), intracranial hemorrhage(n=2, 3.0%), and etiology was not clear(n=5, 7.6%). (2)All children with status epilepticus were divided into four groups according to different valproic acid loading dose(0 mg/kg, 10-15 mg/kg, 16-39 mg/kg, 40 mg/kg). There are no significant differences in gender and age among groups.There were no significant differences in duration of status epilepticus and epileptic treatment efficiency(P=0.402, 0.034). (3)All children were monitored for liver function after the treatment of sodium valproate, and no patient had been found increased alanine aminotransferase.@*Conclusion@#There are no significant differences in the effect of different valproic acid loading doses in children with status epilepticus, and no adverse side effects are observed in children with status epilepticus who received a dose of 40 mg/kg.
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The coronavirus disease 2019 (COVID-19) has caused a global pandemic. All people including children are generally susceptible to COVID-19, but the condition is relatively mild for children. The diagnosis of COVID-19 is largely based on the epidemiological evidence and clinical manifestations, and confirmed by positive detection of virus nucleic acid in respiratory samples. The main symptoms of COVID-19 in children are fever and cough; the total number of white blood cell count is usually normal or decreased; the chest imaging is characterized by interstitial pneumonia, which is similar to other respiratory virus infections and infections. Early identification, early isolation, early diagnosis and early treatment are important for clinical management. The treatment of mild or moderate type of child COVID-19 is mainly symptomatic. For severe and critical ill cases, the oxygen therapy, antiviral drugs, antibacterial drugs, glucocorticoids, mechanical ventilation or even extracorporeal membrane oxygenation (ECMO) may be adopted, and the treatment plan should be adjusted timely through multi-disciplinary cooperation.
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Child , Humans , Betacoronavirus , Coronavirus Infections , Diagnosis , Pathology , Therapeutics , Pandemics , Pneumonia, Viral , Diagnosis , Diagnostic Imaging , Pathology , TherapeuticsABSTRACT
Mechanical ventilation is an important rescue method for critically ill children, and timely evacuation is crucial for children with invasive mechanical ventilation.Difficult or delayed evacuation can prolong the hospitalization time of children and increase the complications and mortality of mechanical ventilation.The pathological mechanism of withdrawal difficulty is complex and affected by many factors.Early rehabilitation intervention is very important to improve the prognosis of children with withdrawal difficulty.This study briefly introduced the definition, etiology and comprehensive rehabilitation intervention of difficult withdrawal.
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Objective:To explore the effect of valproic acid with different loading doses in treatment of children with status epilepticus.Methods:The data of children who were hospitalized in the intensive care unit of the Children′s Hospital Affiliated to Zhejiang University because of status epilepticus from January 1, 2013 to December 31, 2017 were collected.All the patients were divided into different groups according to loading dose of valproic acid.The effect were analyzed in different groups.Results:(1)There were 66 children with status epilepticus were admitted, including 35 males and 31 females.Among all children with status epilepticus, the etiology included epilepsy( n=36, 54.5%), intracranial infection( n=16, 24.2%), hypoxic asphyxia ( n=3, 4.5%), intracranial tumor( n=2, 3.0%), abnormal brain development( n=2, 3.0%), intracranial hemorrhage( n=2, 3.0%), and etiology was not clear( n=5, 7.6%). (2)All children with status epilepticus were divided into four groups according to different valproic acid loading dose(0 mg/kg, 10-15 mg/kg, 16-39 mg/kg, 40 mg/kg). There are no significant differences in gender and age among groups.There were no significant differences in duration of status epilepticus and epileptic treatment efficiency( P=0.402, 0.034). (3)All children were monitored for liver function after the treatment of sodium valproate, and no patient had been found increased alanine aminotransferase. Conclusion:There are no significant differences in the effect of different valproic acid loading doses in children with status epilepticus, and no adverse side effects are observed in children with status epilepticus who received a dose of 40 mg/kg.
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Adenovirus is one of the common pathogens causing respiratory tract infection in children, which can cause severe pneumonia.Severe adenovirus pneumonia has an acute onset, rapid progress, and many complications, but there is no specific treatment and the mortality rate is high.Mechanical ventilation is an important means of respiratory support for the treatment of severe adenoviral pneumonia, and ventilator-associated lung injury is an inevitable drawback of mechanical ventilation.ECMO can replace and support cardiopulmonary function for a long time, reduce the occurrence of such damage, and improve oxygenation.When patients with severe adenovirus pneumonia develop respiratory failure or ARDS, and conventional treatment fails to improve hypoxemia, or accompanied by air leakage and other complications, ECMO treatment should be considered.However, there are few relevant studies in China, and further experience needs to be accumulated in the selection of respiratory support modes, intervention opportunities and management points of ECMO respiratory support for severe adenovirus pneumonia.
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Adenovirus is one of the common pathogens causing respiratory tract infection in chil﹣dren,which can cause severe pneumonia. Severe adenovirus pneumonia has an acute onset,rapid progress,and many complications,but there is no specific treatment and the mortality rate is high. Mechanical ventilation is an important means of respiratory support for the treatment of severe adenoviral pneumonia,and ventilator﹣associated lung injury is an inevitable drawback of mechanical ventilation. ECMO can replace and support cardiopulmonary function for a long time,reduce the occurrence of such damage,and improve oxygenation. When patients with severe adenovirus pneumonia develop respiratory failure or ARDS,and conventional treat﹣ment fails to improve hypoxemia,or accompanied by air leakage and other complications,ECMO treatment should be considered. However,there are few relevant studies in China,and further experience needs to be ac﹣cumulated in the selection of respiratory support modes,intervention opportunities and management points of ECMO respiratory support for severe adenovirus pneumonia.
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The main pathophysiological features of acute respiratory distress syndrome (ARDS) are alveolitis edema,collapse and V/Q ratio imbalance. Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference recommends that the lung protective ventilation strategy be the first choice for mechanical ventilation of PARDS with small tidal volume and high positive end-expiratory pressure (PEEP) used to improve oxygenation. High PEEP is an important technical tool for the " Open Lung Con-cept". It is beneficial to improve oxygenation through the operation of lung recruitment (RM) and the main-tenance of alveolar open. High PEEP reduced the formation of pulmonary edema in animal experimental mod-els. Large-scale adult randomized controlled trials have shown that high PEEP may reduce mortality in patients with severe hypoxemia,but it is currently subject to some challenges. Simultaneously,high PEEP and ventilator-induced lung injury(VILI) caused by excessive lung expansion are closely related,and increase the incidence of barotrauma and pneumothorax. High PEEP may reduce the volume of blood returning to the heart,reduce cardiac output,and also reduce cerebral perfusion pressure and aggravate brain edema. It is still a highly controversial issue to use high PEEP to optimize lung recruitment in patients with ARDS and to choose the best PEEP to maintain the alveolar open. It has been suggested that the purpose of lung recruitment is no longer to restore normal lung ventilation,but to provide reasonable arterial oxygen saturation and reduce oxy-gen toxicity priority. PEEP above 10 cmH2 O is suggested to be used to optimize lung recruitment if lung col-lapse is diffuse. When the lung collapse is locally distributed,it is not suitable to use excessive PEEP for RM and other methods can be used to improve V/Q ratio.
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Objective To investigate the efficacy and safety of tigecycline therapy in children with ventilator-associated pneumonia infected by gram-negative bacteria. Methods We conducted a restrospective chart review of children with ventilator-associated pneumonia in a tertiary hospital from May 1,2012 to April 30,2017. Inclusion criteria:positive sputum culture result;receiving tigecycline administration of at least 2 days (4 doses). Clinical data and laboratory results were recorded before and after the therapy. Results Twenty-seven children were enrolled,with the in-hospital mortality of 37. 0％(10/27). Twenty-seven bacteri-a strains were recorded,all of which were gram-negative,with Acinetobacter baumanmii took up the most. Most bacteria were susceptible to tigecycline. Median duration of tigecycline was 10 days ( 3-27 days ) , 40. 7％ patients(11/27) got clinically improvement and 44. 4％(12/27) got pathogen eradication. Sulpera-zone was the most concomitantly used antibiotics. Totally 3 dosage models were observed and model 1(load-ing dose 2 mg/kg,maintain dose 1 mg/kg) and model 2 ( loading dose 1. 5 mg/kg,maintain dose 1 mg/kg) were the primary. Rate of clinical improvement and microbiology eradication in model 1 group was higher than other groups. No serious adverse effect was detected. Conclusion Tigecycline combined with other a-gents could be used as salvage therapy in gram-negative bacteria infected ventilator-associated pneumonia children and it is tolerated.
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Objective@#To survey the conduction and evaluate the effectiveness of extracorporeal membrane oxygenation (ECMO) therapy in pediatric intensive care unit (PICU) in China mainland.@*Methods@#In a questionnaire-based survey, we retrospectively reviewed the application of ECMO in children's hospital and general hospital in China mainland to summarize and analyze the categories of diseases and prognosis of children treated with ECMO therapy.@*Results@#By December 31, 2017, a total of 23 hospitals using ECMO, including 22 tertiary referral hospitals and 1 secondary hospital, among which 16 were children′s hospitals and 7 were general hospitals. Thirty-seven ECMO equipment was available. A total of 518 patients treated with ECMO, within whom 323 (62.4%) successfully weaned from ECMO and 262 (50.6%) survived to discharge. Among 375 pediatric patients, 233 (62.1%) were successfully weaned from ECMO and 186 (49.6%) survived to discharge. Among 143 newborn patients, 90 (62.9%) successfully weaned from ECMO, 76 (53.1%) survived to discharge. ECMO was applied in veno-arterial (VA) mode to 501 (96.7%) patients, veno-venous (VV) mode to 14 (2.7%) patients, and VV-VA conversion mode to 3 (0.6%) patients. Sixty-nine patients required extracorporeal cardiopulmonary resuscitation (ECPR), including 20 newborn patients (29.0%) and 38 pediatric patients (71.0%), who were all with cardiovascular disease. Neonatal respiratory distress syndrome (26/61), persistent pulmonary hypertension of the newborn (PPHN) (12/61), and meconium aspiration syndrome (MAS) (11/61) are the most common pulmonary diseases in newborn patients; among whom, infants with PPHN had highest survival rate (10/12), followed by MAS (9/11). Among newborn patients with cardiovascular diseases, those who admitted were after surgery for congenital cardiac disease were the most common (54/82), while those with septic shock had the highest survival rate (2/3). In pediatric pulmonary diseases, acute respiratory distress syndrome was the most common (42/93), while plastic bronchitis was with the highest survival rate (4/4), followed by viral pneumonia (13/16). Among pediatric cardiovascular diseases, congenital cardiac defect was the most common (124/282), while fulminant myocarditis had the highest survival rate (54/77).@*Conclusion@#The application of ECMO as a rescue therapy for children with severe cardiopulmonary failure has dramatically developed in China mainland.
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As one of the cyclical substitution technologies, extracorporeal membrane oxygenation (ECMO) has rapidly developed in recent years. This technology can provide effective circulation function support and win valuable time for heart restoration or heart transplantation. It is an effective measure to treat refractory heart failure. In recent years,ECMO has been widely used in the pediatric critical illness area to save the lives of a large number of critically ill children. In order to enable pediatric intensive care physicians to further understand the role of ECMO in assisting and replacing cardiac function,the paper will provide a brief introduction to this aspect.
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Acute liver failure has a high mortality and leads to hyperbilirubinemia which could process to multiple organ failure and death. The bilirubin adsorption treatment can specifically remove a large amount of bilirubin in the body and can reuse own plasma and albumin to reduce allergic reactions. Bilirubin adsorbent materials including adsorbent resin and polymer adsorbent,show better effects in liver failure. Bili-rubin adsorption is used less in pediatric acute liver failure in domestic,it needs to perform multi-center clini-cal cooperative research to evaluate the response.
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Drowning is one of the main causes of accidental injuries common in children.Hypoxia and pulmonary edema occur due to inhalation of fluids after drowning.How to identify and deal with pulmo-nary edema of drowning early is related to the improvement of survival rate and reduction of complications. Timely and effectively mechanical ventilation,reasonable parameter selection of ventilator and other compre-hensive treatments are the key to control pulmonary edema.
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Acute abdomen pain is one of the most common emergency in pediatrics.It mainly refers to abdomi-nal symptoms and signs,always accompanied by systemic inflammatory response,which caused by the rapid pathological changes of tissues or organs in abdominal,pelvic and retroperitoneal.Since acute progression of onset and a variety of diseases caused by acute abdomen pain in children,furthermore,infants and young children will not accurately use words to express,generally do not cooperate with the physical examination and a variety of laboratory tests,other factors and so on,which causes early diagnosis is difficult.If without timely diagnosis and treatment,the consequences will be often serious.This article briefly introduces the diagnosis and emergency treatment of acute abdomen pain in children.
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Objective To review multi-center experience on rescue use of extracorporeal membrane oxygenation(ECMO) in pediatric patients with acute fulminant myocarditis and to investigate its short-term outcome in China.Methods The survey was conducted in 28 tertiary hospitals in China mainland.All children<18 years who had been supported with non-open chest ECMO to rescue acute fulminant myocarditis in PICU were reviewed.Results Twenty-three of 63 patients with ECMO support were diagnosed acute fulminant myocarditis.Their mean age was(86.3±48.8)months,mean weight was(25.8±12.1)kg,and mean left ventricular ejection fraction was(39.5±15.6)%.Eighteen patients(78.3%) survived to discharge and 5 cases(21.7%) died.The average length of ECMO was(119.1±57.3)h,(110.6±42.7)h for survival,(150.0±93.8)h for nonsurvival.There was no statistically difference between survival and death in ECMO support time(P=0.41).The mean arterial pressure increased from(60.7±23.7)mmHg(1mmHg=0.113kPa) of the beginning to(72.1±9.8)mmHg at 24h after ECMO treatment,and increase of mean arterial pressure was higher in the survival compared with the nonsurvival(P=0.04).The mean serum lactate decreased from(6.8±5.1)mmol/L at ECMO initiation to(2.9±2.6)mmol/L at 24h after ECMO treatment,and decrease of serum lactate was higher in survival group compared to nonsurvival group(P<0.001).Twenty-one patients(91.3%) were decanulated from ECMO successfully.Three patients died within 30 days after ECMO support,and eighteen patients survived to hospital discharge.The overall survival rate was 78.3%.There were no significant difference between the death and the survival in ECMO support time(P=0.41) and medical cost(P=0.24).The most common complications during ECMO were bleeding and disfunction of oxygenator.Of the 18 survivors,15 were followed up,4 experienced obvious sequelae,and 2 had neurologic issues.Conclusion ECMO is an effective hemodynamic support treatment that confers better clinical outcome for pediatric patients with acute fulminant myocarditis.
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Objective To review multi-center experience on rescue use of extracorporeal membrane oxygenation(ECMO) in pediatric patients with respiratory failure and to investigate its short-term outcome in China.Methods The survey was conducted in 4 tertiary hospitals in China mainland.All children<18 years old who had been supported with non-open chest ECMO to rescue respiratory failure in PICU were reviewed.Results Twenty-one patients with ECMO support were diagnosed respiratory failure.Male was 14,female was 7.Twelve patients successfully weaned off ECMO, 8 patients survived to discharge and 13 died.The largest part of protopathy was severe pneumonia(33%)and acute respiratory distress syndrome(29%).Their mean age was 29.0(9.0,81.5)months, mean weight was 12.0(9.0,20.8)kg,and mean OI index was 31.5(19.2,41.0).The average length of ECMO run was 149.0(91.2,242.0)hours.The blood gas analysis showed that PO2 increased from 49.5(40.4,61.9)mmHg(1mmHg=0.133kPa) at the beginning to 65.0(42.6,120.5)mmHg at 24h after ECMO treatment,and the increase of PO2 was higher in the survival compared with the nonsurvival[52.0(1.8,89.4) mmHg vs.8.2(-15.1,33.9) mmHg,P=0.036].The SO2 increased from 80.0%(70.4%,91.8%)at ECMO initiation to 98.0%(95.6%,100%)at 24h after ECMO treatment,and increase of SO2 was higher in survival group compared to that of nonsurvival group[23.5%(11.4%,27.1%) vs.4.3%(2.4%,23.8%),P=0.039].VV mode had higher survival rate than VA mode(3/3 vs.5/18).The longer the use of ventilator before ECMO,the mortality rate increased as well.The mechanical ventilation time before ECMO was significantly longer in nonsurvival group than that in the survival group[4.5(2.5,12.0)h vs.1.6(1.0,2.2)h,P=0.015].The most common complications during ECMO run were bleeding and disfunction of oxygenator.Conclusion ECMO is an effective support treatment for the pediatric patients with respiratory failure,which significantly improves oxygenation.
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Tracheal gas insufflation is a non conventional respiratory support technology. It might avoid severe CO2 retention in lung protective ventilation strategy, reduce ventilator-associated lung injury, which was recommented recently. In this article,we made a brief introduction of the principle,classification and clinical applications of tracheal gas insufflation technique.