Paediatric Intensive Care Unit, Department of Child Health, King's College Hospital, Denmark Hill, London, United Kingdom.
Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom.
Crit Care Med. 2018 Jul;46(7):e677-e683. doi: 10.1097/CCM.0000000000003156.
There are no studies in pediatrics evaluating the progression of acute kidney injury in septic shock. We investigated the evolution of sepsis-associated acute kidney injury and its association with systemic hemodynamics in children with fluid-refractory septic shock.
Prospective cohort study.
PICU of a tertiary care hospital.
All patients with fluid-refractory septic shock (n = 61) between September 2010 and February 2014.
Hemodynamic variables using noninvasive ultrasound cardiac output monitor were measured at admission and 6 hourly thereafter till 48 hours. We used the Kidney Disease: Improving Global Outcomes criteria to define and stage acute kidney injury. Associations between various hemodynamic variables and development of acute kidney injury were evaluated. Severe acute kidney injury was defined as stage 2 or 3 acute kidney injury and was compared with no acute kidney injury or stage 1 acute kidney injury.
Severe acute kidney injury developed in 29.5% (n = 18) of the 61 children with fluid-refractory septic shock, whereas 43 patients (70.49%) had either no or stage 1 acute kidney injury. Most patients who developed acute kidney injury did so within the first 48 hours of PICU admission. Severe acute kidney injury conferred a three-fold increased risk of death by day 28 (hazard ratio, 3.23; 95% CI, 1.52-6.67; p = 0.002), longer ICU stay, and increased duration of mechanical ventilation. Central venous pressure at presentation was higher in severe acute kidney injury by 5 cm H2O. Highest lactate in the first 24 hours of PICU admission, low diastolic blood pressure, low systemic vascular resistance index at admission were associated with severe acute kidney injury. This model reliably predicted stage 2/3 acute kidney injury by day 3 with area under the curve equals to 94%; 95% CI, 88.3-99.99. None of the other hemodynamic variables showed any association with severe acute kidney injury.
Manifestations of sepsis-associated acute kidney injury often occur early after PICU admission and is associated with increased morbidity and mortality. There is a need to develop a predictive model in septic shock which could facilitate early detection of acute kidney injury.
儿科领域尚无研究评估脓毒性休克患者急性肾损伤的进展情况。我们旨在研究液体复苏无效性脓毒性休克患儿中脓毒症相关急性肾损伤的演变情况及其与全身血流动力学的关系。
前瞻性队列研究。
三级医院的 PICU。
2010 年 9 月至 2014 年 2 月期间所有液体复苏无效性脓毒性休克患儿（n=61）。
使用非侵入性超声心输出量监测仪测量入院时和此后每 6 小时的血流动力学变量，直至 48 小时。我们采用肾脏病：改善全球预后标准来定义和分期急性肾损伤。评估了各种血流动力学变量与急性肾损伤发展之间的关系。严重急性肾损伤定义为 2 期或 3 期急性肾损伤，并与无急性肾损伤或 1 期急性肾损伤进行比较。
61 例液体复苏无效性脓毒性休克患儿中，29.5%（n=18）发生严重急性肾损伤，而 43 例（70.49%）患儿无急性肾损伤或仅有 1 期急性肾损伤。大多数发生急性肾损伤的患儿是在 PICU 入院后 48 小时内发生的。严重急性肾损伤使患儿在第 28 天的死亡风险增加了 3 倍（危险比，3.23；95%置信区间，1.52-6.67；p=0.002），ICU 住院时间延长，机械通气时间延长。严重急性肾损伤患儿的中心静脉压在入院时高 5cmH2O。入院后 24 小时内的最高乳酸水平、舒张压低、入院时的全身血管阻力指数低与严重急性肾损伤相关。该模型在第 3 天可靠地预测到 2/3 期急性肾损伤，曲线下面积为 94%；95%置信区间，88.3-99.99。其他血流动力学变量均与严重急性肾损伤无关联。
脓毒症相关急性肾损伤的表现常在 PICU 入院后早期发生，与发病率和死亡率增加有关。需要在脓毒性休克中建立预测模型，以便早期发现急性肾损伤。
