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Objective:To study the predictive value of vasoactive-inotropic score (VIS), fluid overload (FO) and lactate level for the outcome of preterm infants with refractory septic shock.Methods:Preterm infants diagnosed with refractory septic shock and required hydrocortisone treatment in our Department from January 2016 to December 2021 were analyzed retrospectively. Preterm infants were assigned into three gestational age groups (<28 weeks, 28-31 weeks, 32-36 weeks). According to the outcome of the disease, the children were further divided into good prognosis group and poor prognosis group. The relationship between the maximum VIS, FO and the mean lactic acid before hydrocortisone and the outcome of refractory septic shock was analyzed by receiver operating characteristic (ROC) curve, the cut-off point of ROC curve was calculated to obtain the predictive efficacy of the three indicators for the outcome of refractory septic shock in preterm infants.Results:A total of 50 preterm infants with refractory septic shock and received hydrocortisone treatment were enrolled, including 20 in the good prognosis group and 30 in the poor prognosis group. There were no significant differences in the maximum VIS, FO and mean lactic acid before hydrocortisone treatment between the two groups of gestational age of <32 weeks ( P> 0.05). The maximum VIS, FO and mean lactic acid of gestational age of 32-36 weeks in the poor prognosis group were higher than those in the good prognosis group, VIS: 56.1±15.7 vs. 37.1±12.9, FO (%): 108.2 (78.6,137.7) vs. 55.5 (10.3, 100.7), and mean lactic acid (mmol/L): 8.3 (4.6, 12.0) vs. 4.8 (-0.8, 10.5), all P<0.05. The area under the ROC curve of the mean lactic acid was the largest, the cut-off value was 4.1 mmol/L, and the Youden index was 1.732. Conclusions:VIS, FO and lactate level are difficult to be used for determining the outcome of refractory septic shock in preterm infants of <32 weeks. While the mean lactic acid has the best predictive performance in preterm infants of 32-36 weeks.
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Objective:To study the threshold of fluid overload (FO) and its risk factors in neonatal septic shock.Methods:From January 2019 to November 2020, clinical data of infants with septic shock hospitalized in the neonatal department of our hospital were reviewed. With poor prognosis as the outcome, ROC curve was drawn based on 24 h (from the beginning of septic shock), 48 h and 72 h FO value. FO cutoff value was determined as area under curve (AUC) reached maximum. Risk factors of FO were analyzed between FO<cutoff value group and FO≥cutoff value group.Results:A total of 152 eligible cases were included and the cutoff value of 48 h FO was determined as 43.3%. 116 cases were in FO<43.3% group and 36 cases were in FO≥43.3% group. FO≥43.3% group had smaller gestational age (GA), birth weight (BW), 1 min Apgar score, 5 min Apgar score and lower PLT, PCT, pH, and ALB level compared with FO<43.3% group. Meanwhile, FO≥43.3% group had significantly higher shock score, bedside septic shock scores (bSSS), lactic acid level, higher incidences of WBC <5×10 9/L and albumin infusion compared with FO<43.3% group. As for prognostic outcome, FO≥43.3% group had significantly higher incidences of neonatal persistent pulmonary hypertension, severe cerebral hemorrhage, periventricular leukomalacia, acute kidney injury, severe brain injury, multiple organ dysfunction syndrome, disseminated intravascular coagulation and 28 d all-cause mortality rate than FO<43.3% group ( P<0.05). Logistic regression analysis showed risk factors associated with FO≥43.3% were BW ( OR=0.998, 95% CI 0.998~0.999, P<0.05), pH ( OR=0.018, 95% CI 0.000~0.990, P<0.05) and bSSS ( OR=1.619, 95% CI 1.134~2.311, P<0.05). The cutoff values were BW 1 830 g, pH 7.15 and bSSS 0.5. Conclusions:The 48 h FO with cutoff value of 43.3% has the highest predictive value for prognostic outcome in neonates with septic shock. FO≥43.3% is associated with more adverse outcomes. Infants with septic shock who have lower BW, lower pH and higher bSSS are more likely to develop FO≥43.3%.
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Objective:To study the predictive value of vasoactive-inotropic score (VIS), shock score and lactate level for the outcome of term infants with septic shock.Methods:From January 2019 to October 2020, clinical data of term infants with septic shock admitted to our department were reviewed. According to their clinical outcome, the infants were assigned into the survival group and the deceased group and the differences of the two groups were compared. Logistic regression was used to determine the risk factors of mortality in term infants with septic shock. Receiver operating characteristic curve was used to compare the predictive efficacy of VIS, shock score and lactate level for the outcome of septic shock.Results:Significant differences existed between the survival group and the deceased group in the following: maximum VIS, maximum shock score, maximum lactate level, the mean value of VIS during the second 24 h, the mean value of lactate during the first and second 24 h ( P < 0.05). Meanwhile, maximum VIS ( OR = 1.038, 95% CI 1.014~1.063), maximum shock score ( OR = 2.372, 95% CI 1.126~4.999) and the mean value of lactate during the first 24h ( OR = 2.983, 95% CI 1.132~7.862) were correlated with mortality in the infants ( P < 0.05). The area under the curve of maximum VIS was the most prominent, with 58.5 as cut-off. Conclusions:Among the three indicators, VIS has the best predictive value for mortality outcome in term infants with septic shock, followed by shock score and lactate level.
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Objective:To study the efficacy of norepinephrine in the treatment of neonates with septic shock.Methods:A prospective observation study of neonates with septic shock, who received norepinephrine in the neonatal intensive care unit of Guangdong Women and Children's Hospital from January 2019 to November 2020. All infants had functional echocardiography for hemodynamic monitoring before norepinephrine treatment and 1 hour thereafter blood pressure, heart rate, arterial blood gas analyses were recorded at the same time. The intravenous fluid volume and urine volume from the diagnosis of shock to the commencement of norepinephrine therapy (T0) and 24 hours thereafter (T1) were recorded, and the hemodynamic parameters, vasoactive drugs and clinical outcomes were analyzed.Results:A total of 66 newborns were enrolled, including 27 cases of mild shock, 33 cases of moderate shock and 6 cases of severe shock. 48 were male infants, 38 cases were premature infants. The gestational age was (35.2±4.1) weeks and the birth weight was (2 476±909) g. The median time of shock diagnosis was 2 days after birth, and the median shock score was 4 points. The median time from the diagnosis of shock to the start of norepinephrine treatment was 7.5 hours. Compared with that before norepinephrine treatment, stroke volume, stroke volume index, cardiac output, cardiac index, left ventricular ejection fraction, shortening fraction, systolic blood pressure, diastolic blood pressure, mean arterial pressure, blood pH and BE at 1 hour after treatment were increased, heart rate and blood lactic acid were decreased, the differences were statistically significant ( P<0.05). Urine volume was increased 24 hours after treatment ( P<0.05), and fluid overload decreased ( P<0.05). The maximum dopamine dose, the down-regulation time and duration of vasoactive drugs were positively correlated with the time to start norepinephrine therapy ( r=0.325、 r=0.383、 r=0.319, P<0.05). Among the 66 infants, 58 infants with shock had been corrected and 14 infants died within 28 days. Conclusions:Norepinephrine is effective and feasible in the treatment of neonatal septic shock and can significantly improve hemodynamic parameters.
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Objective:To determine the dose-effect relationship of oxycodone inhibiting responses to endotracheal intubation with combination of etomidate-rocuronium during induction of general anesthesia.Methods:A total of 120 patients, aged 20-63 yr, with body mass index of 18.0-25.2 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective surgery under general anesthesia with tracheal intubation, were divided into 4 groups ( n=30 each) using a random number table method: group O 0.15, group O 0.23, group O 0.34 and group O 0.51.In O 0.15, O 0.23, O 0.34 and O 0.51 groups, oxycodone 0.15 mg/kg, 0.23 mg/kg, 0.34 mg/kg and 0.51 mg/kg were injected intravenously, respectively, 3 min later etomidate 0.3 mg/kg and rocuronium 0.8 mg/kg were intravenously injected in turn, and tracheal intubation was performed using Macintosh laryngoscope.Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure immediately before intubation and the peak levels of HR, BP and diastolic blood pressure within 3 min after intubation were recorded.The response to endotracheal intubation was defined by the SBP and (or) HR having increased by more than 30% following intubation.The occurrence of adverse events during induction of anesthesia were recorded. Results:The rate of response to endotracheal intubation was 97%, 73%, 27%, and 3% in O 0.15, O 0.23, O 0.34 and O 0.51 groups, respectively.The median effective dose (ED 50) (95% confidence interval) of oxycodone inhibiting responses to endotracheal intubation was 0.259 (0.230-0.292) mg/kg, and the 95% effective dose (ED 95) (95% confidence interval) was 0.387 (0.358-0.420) mg/kg.Only the incidence of hypotension (27%) was significantly higher in group O 0.51 than in the other 3 groups ( P<0.05). Conclusion:With combination with etomidate-rocuronium, the ED 50 and ED 95 of oxycodone inhibiting responses to endotracheal intubation performed using Macintosh laryngoscope during induction of general anesthesia are 0.259 mg/kg and 0.387 mg/kg, respectively, and the optimum dose 0.51 mg/kg is recommended.
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Objective:To study the clinical value of neonatal shock score (NSS) and septic shock score (SSS) in the evaluation of mortality and serious complications of neonatal refractory septic shock.Method:From January 2019 to November 2020, clinical data of neonates with septic shock admitted to Neonatal Department of our hospital were retrospectively reviewed. According to the final outcomes, neonates were assigned into good prognosis group (neonates survived without serious complications) and poor prognosis group (neonates were dead within 28 days after birth and/or had serious complications). The NSS and SSS were calculated according to the worst value of each index during the septic shock course. SSS included computed septic shock score (cSSS) and bedside septic shock score (bSSS). The receiver operating characteristic (ROC) curve was used to analyze the efficacy of each scoring system evaluating the risk of poor prognosis due to septic shock. The correlation of each scoring system with the duration of vasoactive drugs was analyzed using Spearman rank correlation analysis.Result:A total of 72 neonates were enrolled, including 45 in good prognosis group and 27 in poor prognosis group. The vasoactive drug score, serum lactate level, NSS and cSSS in poor prognosis group were significantly higher than good prognosis group ( P<0.05).And bSSS score showed no significant differences between the two groups ( P>0.05). The area under the ROC curve (AUC) of NSS and cSSS predicting the adverse prognosis of neonates with septic shock were 0.644 (95% CI 0.510~0.777, P<0.05) and 0.765 (95% CI 0.654~0.877, P<0.05). The best cut-off values for NSS and cSSS predicting poor prognosis were 4.0 and 80.5, respectively. The positive predictive value (PPV) (81.3% vs. 47.5%) and negative predictive value (NPV) (75.0% vs. 70.6%) of cSSS were higher than NSS. Spearman rank correlation analysis showed that cSSS was positively correlated with the duration of vasoactive drugs( r=0.487, P<0.01). Conclusion:Both shock scoring systems have an evaluation value for the prognosis of neonatal septic shock. The evaluation value of cSSS is better than NSS, and can be used as a main tool for the evaluation of neonatal refractory septic shock.
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Objective:To summarize the clinical characteristics and experiences in the diagnosis and treatment of congenital tuberculosis.Methods:This study involved four infants with congenital tuberculosis diagnosed in Guangdong Women and Children Hospital from January 2010 to January 2020. Moreover, publications of 52 congenital tuberculosis cases from Chinese hospitals between January 1994 and January 2019 were retrieved from Wanfang Database, China National Knowledge Infrastructure and PubMed. Clinical data of all patients were retrospectively analyzed.Results:All four cases we reported here were preterm infants with the onset of the disease at 14-30 d after birth and received anti-tuberculosis treatment. The interval between disease onset and diagnosis was 1-34 d. One baby was cured, one was improved, while the other two died. The median age at the onset of the disease in these 56 cases (including the four we reported and 52 from literature) was 14.5 d (7.0-20.7 d) and the median interval between the onset and diagnosis was 10.5 d (7.5~22.0 d). Forty-eight (88.9%) out of the 54 mothers were suffered from active tuberculosis during the perinatal period, including 16 diagnosed before delivery. The main clinical symptoms in these neonates were fever (82.1%, 46/56), respiratory distress (69.6%, 39/56), drowsiness and/or irritation (57.1%, 32/56), cyanosis (53.6%, 30/56), feeding difficulties (53.6%, 30/56), hepatomegaly (48.2%, 27/56) and splenomegaly (41.1%, 23/56). The positive rates of acid-fast staining, culture and polymerase chain reaction detection of Mycobacterium tuberculosis in sputum smears or gastric juice were all less than 33.3%, and the positive rate of spot test for Mycobacterium tuberculosis infection was 7/12. Chest X-ray showed miliary nodules and diffused nodules-patchy in 37.0% (20/54) and 25.9% (14/54) of the patients, respectively. Abdominal ultrasonography found 52.4% (11/21) with hepatomegaly and/or splenomegaly and 47.6% (10/21) with multiple low-density nodules in liver and spleen. The misdiagnosis rate was 28.6% (16/56). The overall mortality rate was 51.8% (29/56). However, the figure was 28.9% (11/38) in infants with anti-tuberculosis treatment and 18/18 in those without. Conclusions:Nonspecific clinical manifestations of congenital tuberculosis, together with low detection rate through laboratory tests, may lead to a higher rate of misdiagnosis and mortality. Therefore, a comprehensive assessment of the mothers of infants with suspected congenital tuberculosis is necessitated. Diagnosis and effective anti-tuberculosis treatment as early as possible are essential to improve the prognosis.
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The cerebral hemodynamic disorders are most likely to occur in preterm infants, especially in extremely preterm infants with gestational age <28 weeks, due to the immaturity of cerebral vascular development and poor autoregulation of cerebral blood flow. Also the neurons, oligodendrocytes and their precursors in preterm infants are abnormally sensitive to hypoxia and ischemia with low tolerance and high vulnerability, which lead to a higher incidence of brain damage and neurological sequelae in preterm infants than that in full-term infants. Because brain injury in the premature often lacks the obvious nervous system symptom and the sign clinically, it is easy to be misdiagnosed and hence suitable treatment opportunity is missed. Cranial ultrasonography, MRI and EEG are the special examinations for early diagnosis of brain injury in preterm infants. In the diagnosis of early intracranial hemorrhage, cranial ultrasonography is superior to both MRI and EEG, but MRI especially DWI has the highest diagnostic value in the evaluation of leukoencephalomalacia, and EEG plays a supporting role in diagnosis of brain injury in each period. The three techniques have their own advantages and disadvantages. In clinical practice, if three techniques can be rationally used for the diagnosis of brain damage in preterm infants, it would be helpful to detect the disease in time and treat appropriately as soon as possible, and thus reduce the neurological sequelae and disability in preterm infants, and improve the long-term prognosis.