Pelland-Marcotte Marie-Claude, Tucker Catherine, Klaassen Alicia, Avila Maria Laura, Amid Ali, Amiri Nour, Williams Suzan, Halton Jacqueline, Brandão Leonardo R
Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
Lancet Haematol. 2019 Mar;6(3):e144-e153. doi: 10.1016/S2352-3026(18)30224-2. Epub 2019 Feb 13.
Little is known about severe pulmonary embolism in children. We aimed to report pulmonary embolism outcomes, identify risk factors for unfavourable outcomes, and evaluate the discriminative ability of two clinical-severity indices in children.
In this retrospective cohort study, we included consecutive patients aged 18 years or younger with acute pulmonary embolism, objectively diagnosed radiologically or pathologically, between Jan 1, 2000, and Dec 31, 2016, from two Canadian paediatric hospitals (The Hospital for Sick Children, Toronto, ON, and the Children's Hospital of Eastern Ontario, Ottawa, ON). Exclusion criteria were sudden death without radiological or pathological pulmonary embolism confirmation and non-thromboembolic pulmonary embolism. The primary outcome was a composite of unfavourable outcomes of pulmonary embolism-related death and pulmonary embolism recurrence or progression. Potential predictors of the composite unfavourable outcome (ie, age at pulmonary embolism diagnosis, sex, underlying cardiac disease, severity of the pulmonary embolism, presence of a central venous catheter, associated venous thromboembolism, family history of thrombosis, treatment modalities, thrombophilia, obesity, and recent surgery) were explored with logistic regression. We calculated pulmonary embolism severity index (PESI) and simplified PESI (sPESI) using age-adjusted parameters; we estimated the ability of PESI and sPESI to predict mortality using receiver-operating characteristic (ROC) curve analysis.
Of the 170 patients included, 37 (22%) had massive, 12 (7%) submassive, and 121 (71%) non-massive pulmonary embolism. Patients with massive or submassive pulmonary embolism were younger (median age 12·5 years [IQR 0·6-15·1] vs 14·4 years [9·3-16·1], p<0·0001), more likely to have a cardiac condition (16 [33%] vs 17 [14%] patients, p=0·009), and had more central venous catheters (29 [59%] vs 48 [40%] patients, p=0·027) than patients with non-massive pulmonary embolism. Aggressive treatment modalities were more commonly used in massive or submassive pulmonary embolism (22 [45%] vs 7 [6%] patients, p<0·0001). Of the predictors tested, only pulmonary embolism severity was associated with the composite unfavourable outcome in the multivariable analysis (odds ratio 3·53, 95% CI 1·69-7·36; p=0·011). The area under the ROC curve for PESI to predict 30-day mortality was 0·76 (95% CI 0·64-0·87). Sensitivity of sPESI was 100% and specificity was 30%.
Massive or submassive pulmonary embolism led to higher rates of unfavourable outcomes than non-massive pulmonary embolism in children. Further adaptations of PESI and sPESI are required to improve their clinical usefulness in paediatric patients.
Trainee Start-Up Fund (The Hospital for Sick Children).
关于儿童严重肺栓塞的情况人们了解甚少。我们旨在报告肺栓塞的结局，确定不良结局的危险因素，并评估两种临床严重程度指数在儿童中的鉴别能力。
在这项回顾性队列研究中，我们纳入了2000年1月1日至2016年12月31日期间来自加拿大两家儿科医院（安大略省多伦多市的病童医院和安大略省渥太华市的东安大略儿童医院）的18岁及以下经影像学或病理学客观诊断为急性肺栓塞的连续患者。排除标准为未经影像学或病理学证实的肺栓塞的猝死以及非血栓栓塞性肺栓塞。主要结局是肺栓塞相关死亡、肺栓塞复发或进展的不良结局的综合情况。通过逻辑回归探索综合不良结局的潜在预测因素（即肺栓塞诊断时的年龄、性别、潜在心脏病、肺栓塞的严重程度、中心静脉导管的存在、相关静脉血栓栓塞、血栓形成家族史、治疗方式、易栓症、肥胖和近期手术）。我们使用年龄校正参数计算肺栓塞严重程度指数（PESI）和简化PESI（sPESI）；我们使用受试者操作特征（ROC）曲线分析评估PESI和sPESI预测死亡率的能力。
在纳入的170例患者中，37例（22%）为大面积肺栓塞，12例（7%）为次大面积肺栓塞，121例（71%）为非大面积肺栓塞。大面积或次大面积肺栓塞患者较年轻（中位年龄12.5岁[四分位间距0.6 - 15.1] vs 14.4岁[9.3 - 16.1]，p<0.0001），更可能患有心脏病（16例[33%] vs 17例[14%]患者，p = 0.009），且中心静脉导管更多（29例[59%] vs 48例[40%]患者，p = 0.027），高于非大面积肺栓塞患者。积极的治疗方式在大面积或次大面积肺栓塞中更常用（22例[45%] vs 7例[6%]患者，p<0.0001）。在测试的预测因素中，多变量分析中仅肺栓塞严重程度与综合不良结局相关（比值比3.53，95%置信区间1.69 - 7.36；p = 0.011）。PESI预测30天死亡率的ROC曲线下面积为0.76（95%置信区间0.64 - 0.87）。sPESI的敏感性为100%，特异性为30%。
在儿童中，大面积或次大面积肺栓塞导致的不良结局发生率高于非大面积肺栓塞。需要对PESI和sPESI进行进一步调整以提高它们在儿科患者中的临床实用性。
实习生启动基金（病童医院）。
