中心静脉压升高与小儿感染性休克患者死亡率增加相关。
Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients.
作者信息
Choi Seung Jun, Ha Eun-Ju, Jhang Won Kyoung, Park Seong Jong
机构信息
Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Republic of Korea.
出版信息
BMC Pediatr. 2018 Feb 13;18(1):58. doi: 10.1186/s12887-018-1059-1.
BACKGROUND
Central venous pressure (CVP) is an important factor affecting capillary blood flow, and it is associated with poor outcomes in adult septic shock patients. However, whether a similar association exists in pediatric patients remains unclear.
METHODS
We retrospectively analyzed data from patients admitted to our pediatric intensive care unit (PICU) between February 2009 and July 2015. Patients were divided into two groups-survivors and nonsurvivors-according to 28-day mortality. The associations between (a) mortality and CVP at 6, 24, 48, and 72 h after initiating treatment for established septic shock was analyzed and (b) initial serum lactic acid levels and 6-h CVP.
RESULTS
Two hundred twenty-six patients were included in this study, and the mortality rate was 29.6% (67 deaths, nonsurvivor group). Initial serum lactic acid levels, Pediatric Risk of Mortality (PRISM) III score, and Vasoactive-Inotropic Score (VIS) within 24 h after PICU admission were significantly higher in the nonsurvivors than in survivors (1.3 [0.9, 2.4] vs. 3.9 [1.6, 8.0] mmol/l, 11.0 [7.0, 15.0] vs. 17.0 [10.0, 21.5], 12.0 [7.0, 25.0] vs. 22.5 [8.0, 55.0], respectively with p-values < 0.001, < 0.001, and 0.009, respectively). In addition, compared to survivors, a greater percentage of nonsurvivors required mechanical ventilation (92.5% vs. 51.6%, p < 0.001) and showed a greater extent of fluid overload at 48 h after admission (3.9% vs. 1.9%, p = 0.006), along with higher 6-h CVP (10.0 [7.0, 16.0] vs. 8.0 [5.0, 11.0] mmHg, p < 0.001). Patient survival according to levels of CVP (CVP < 8 mmHg, CVP 8-12 mmHg, or CVP > 12 mmHg) showed that the CVP > 12-mmHg group had significantly greater mortality rates (50.0%, p = 0.002) than the other groups (21.3% and 27.5%). Furthermore, multivariate analysis identified significant associations of CVP > 12 mmHg, serum lactic acid levels, and the need for mechanical ventilation with mortality (OR: 2.74, 1.30, and 12.51, respectively; 95% CI: 1.11-6.72, 1.12-1.50, and 4.12-37.96, respectively).
CONCLUSIONS
Elevated CVP is an independent risk factor for mortality in pediatric septic shock patients.
背景
中心静脉压（CVP）是影响毛细血管血流的一个重要因素，且与成年脓毒症休克患者的不良预后相关。然而，在儿科患者中是否存在类似关联仍不清楚。
方法
我们回顾性分析了2009年2月至2015年7月间入住我院儿科重症监护病房（PICU）的患者数据。根据28天死亡率将患者分为两组，即存活组和非存活组。分析了（a）确诊脓毒症休克开始治疗后6、24、48和72小时时死亡率与CVP之间的关联，以及（b）初始血清乳酸水平与6小时CVP之间的关联。
结果
本研究共纳入226例患者，死亡率为29.6%（67例死亡，非存活组）。非存活组患者入住PICU后24小时内的初始血清乳酸水平、儿科死亡风险（PRISM）III评分及血管活性药物评分（VIS）显著高于存活组（分别为1.3[0.9，2.4] vs. 3.9[1.6，8.0] mmol/L、11.0[7.0，15.0] vs. 17.0[10.0，21.5]、12.0[7.0，25.0] vs. 22.5[8.0，55.0]，p值分别<0.001、<0.001和0.009）。此外，与存活组相比，非存活组中需要机械通气的比例更高（92.5% vs. 51.6%，p<0.001），入院后48小时液体超负荷程度更大（3.9% vs. 1.9%，p = 0.006），6小时CVP更高（10.0[7.0，16.0] vs. 8.0[5.0，11.0] mmHg，p<0.001）。根据CVP水平（CVP<8 mmHg、CVP 8 - 12 mmHg或CVP>12 mmHg）分析患者生存率，结果显示CVP>12 mmHg组的死亡率（50.0%，p = 0.002）显著高于其他组（21.3%和27.5%）。此外多因素分析确定CVP>12 mmHg、血清乳酸水平及需要机械通气与死亡率显著相关（OR分别为2.74、1.30和12.51；95%CI分别为1.11 - 6.72、1.12 - 1.50和4.12 - 37.96）。
结论
CVP升高是儿科脓毒症休克患者死亡的独立危险因素。
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