McManus M L, Churchwell K B
Multidisciplinary Intensive Care Unit, Children's Hospital, Boston, MA 02115.
Crit Care Med. 1993 May;21(5):706-11. doi: 10.1097/00003246-199305000-00014.
To identify simple, contemporary predictors of both morbidity and mortality in pediatric patients with purpuric sepsis syndrome in order to provide a basis for future study of innovative interventions.
Retrospective study.
An 18-bed multidisciplinary intensive care unit (ICU) in a large pediatric hospital.
A total of 53 patients, ranging in age from 18 days to 17 yrs (mean 4.9 yrs) with either culture-proven meningococcal sepsis or the systemic inflammatory response syndrome with purpura, who were admitted to the ICU during the period from January 1, 1982 through March 15, 1992.
A computerized database was constructed containing the characteristics of these patients at presentation, during the first 24 hrs of hospitalization, and on discharge. Single variables were screened for significance between "good" (intact survival) and "poor" (mortality or survival with significant morbidity) outcome groups. Those variables found to be most significant were then tested for sensitivity, specificity, and predictive value. The best predictors identified in this manner were then compared with the two most-cited prognosticating strategies as applied to these patients.
Coagulopathy (defined as a partial thromboplastin time > 50 secs or serum fibrinogen concentration < 150 mg/dL [4.4 mumol/L]) at the referral site or on ICU admission was identified as an excellent predictor of poor outcome: sensitivity, specificity, positive and negative predictive values of a low serum fibrinogen value, being 81%, 95%, 93%, and 88%, and of prolonged partial thromboplastin time, being 95%, 90%, 86%, and 97%, respectively. Classical prognosticating strategies were found to be inadequately associated with mortality, yet comparable with coagulopathy in identifying patients destined for clinically important morbidity.
We conclude that: a) outcome of pediatric patients with meningococcal sepsis or the systemic inflammatory response syndrome with purpura can be predicted rapidly, more easily, and with overall accuracy superior to classical prognostication strategies by the simple presence or absence of coagulopathy; b) when applied to a contemporary population, classical prognostication strategies lack value for prediction of mortality, yet remain valid for prediction of "poor outcome" (significant morbidity + mortality); c) when evaluating treatment strategies for such patients, the presence of serious coagulopathy may potentially be useful as an index of illness severity.
确定紫癜性脓毒症综合征儿科患者发病和死亡的简单、现代预测指标，为未来创新干预措施的研究提供依据。
回顾性研究。
一家大型儿科医院的拥有18张床位的多学科重症监护病房（ICU）。
共有53例患者，年龄从18天至17岁（平均4.9岁），患有经培养证实的脑膜炎球菌性脓毒症或伴有紫癜的全身炎症反应综合征，于1982年1月1日至1992年3月15日期间入住ICU。
构建一个计算机化数据库，包含这些患者入院时、住院头24小时及出院时的特征。对“良好”（存活完整）和“不良”（死亡或存活但有严重发病情况）结局组之间的单变量进行显著性筛选。然后对那些被发现最具显著性的变量进行敏感性、特异性和预测价值测试。将以这种方式确定的最佳预测指标与应用于这些患者的两种最常引用的预后策略进行比较。
转诊时或入住ICU时的凝血病（定义为部分凝血活酶时间>50秒或血清纤维蛋白原浓度<150mg/dL[4.4μmol/L]）被确定为不良结局的极佳预测指标：低血清纤维蛋白原值的敏感性、特异性、阳性和阴性预测值分别为81%、95%、93%和88%，延长的部分凝血活酶时间的相应值分别为95%、90%、86%和97%。发现经典的预后策略与死亡率的关联性不足，但在识别注定会发生具有临床重要意义的发病情况的患者方面与凝血病相当。
我们得出以下结论：a）对于患有脑膜炎球菌性脓毒症或伴有紫癜的全身炎症反应综合征的儿科患者，通过凝血病的存在与否可快速、更轻松且总体准确性高于经典预后策略地预测结局；b）应用于当代人群时，经典预后策略对死亡率的预测缺乏价值，但对“不良结局”（严重发病+死亡）的预测仍然有效；c）在评估此类患者的治疗策略时，严重凝血病的存在可能作为疾病严重程度的一个指标。
