The presence and persistence of systemic and lung inflammation in children with acute respiratory distress syndrome (ARDS) is the basis for the use of corticosteroids as a therapeutic agent.The trial of ARDS treated with high-dose short-course corticosteroids showed no benefit,even increase motality.At present,the results of randomized controlled trial and meta-analysis suggested that low-dose and replacement-dose methylprednisolone [1-2 mg/(kg· d)] or equivalent types of corticosteroids may decrease the fatality rate,reduce staying days in ICU and the duration of mechanical ventilation.Use of corticosteroids for ARDS in children is still lack of multicenter randomized controlled trial.

ObjectiveTo investigate the effect and outcome of critically illness with acute kidney injury (AKI) treated with continuous veno-venous hemodiafiltration (CVVHDF) in children.Methods Twenty-four cases of critically illness with AKI were treated with CVVHDF in our pediatric intensive care unit from Jan 2008 to Dec 2010.The levels of creatinine (Cr),blood urea nitrogen (BUN),K +,Na + and HCO3- were observed before CVVHDF and 6,12,24,48,72 h after CVVHDF.ResultsCatheter was successfully established for CVVHDF in 24 cases of AKI.The average duration of CVVHDF was 46 h ( 16 ～142 h).The blood levels of Cr and BUN were significantly decreased at 6 h after CVVHDF [ ( 196.3 ±112.4) μmol/L,( 13.3 ± 8.5 ) mmol/L] and 12 h after CVVHDF [ ( 106.1 ± 84.2) μ mol/L,( 10.2 ± 9.7 )mmol/L] as compared to those before treatment [ (340.6 ±298.2) μmol/L,(31.6 ± 11.3) mmol/L] (P ＜0.05,P ＜ 0.01 ).After 48 h of CVVHDF,the Cr,BUN returned to normal range.The imbalance of blood K +,Na +,and HCO3- improved at 6 h after CVVHDF and returned to nomal levels at 24 h.Total 28 d fatality rate was 29.2％ (7/24),and all death cases were complicated with multiple organ dysfunction syndrome.ConclusionCVVHDF therapy for AKI can quickly clear Cr,BUN and excess water,correct electrolyte disorders,improve kidney function in children.

Objective To analyze the incidence,clinical feature and the risk factors of invasive fungal infection in pediatric intensive care unit (PICU). Methods We retrospectively summaried the invasive fungal infection in our PICU from Jan 2007 to Dec 2009 in order to analyze the incidence, clinical feature and the risk factors of invasive fungal infection in PICU. Multiple clinical data were collected such as pediatric critical illness score, mechanical ventilation, urinary drainage tube, indwelling gastric canal and continuous blood purification. Results ( 1 ) The incidence rate of invasive fungal infection was 1.65 % ( 35/2 116 ). The morbidity was 20. 00% ( 7/35 ). ( 2 ) Mean infected day was ( 10. 4 ±- 8. 3 ) d after admission. The clinical manifestations included fungal pneumonia( 60. 0% ), peritonitis ( 14. 3% ), urinary tract infection ( 11.4% ),intestinal tract infection(8. 6% ) ,sepsis(2. 9% ) and meningitis(2. 9% ). All of the patients had used broad spectrum antibiotic. (3) The risk factors of invasive fungal infection included lower pediatric critical illness score, mechanical ventilation, indwelling gastric tube, urinary drainage tube and continuous blood purification.(4) Candia albicans was the predominant pathogen in invasive fungal infection. Conclusion Invasive fungal infection has become one of the main nosocomial infection in PICU. Lung is most commonly involved and candida albicans is the major pathogen. Using antibiotics appropriately, decreasing unnecessary invasive performance,and rationally using antifungal agent mi.ght be effective strategy for invasive fungal infection in PICU.

Objective To investigate the effect of vasoactive intestinal peptide (VIP) and methylprednisolone (MP) on Toll-like receptor (TLR)2/4 mRNA expression in endotoxin (lipopolysaccharide,LPS) induced shock.Methods Ninety Sprague-Dawley rats were randomly divided into LPS group (n =20),LPS + VIP group (n =20),LPS + MP group (n =20),LPS + VIP + MP group (n =20) and control group (n =10).LPS group injected intravenously LPS (E Coli O55B5) 10 mg/kg.LPS + VIP group,LPS + MP group and LPS + VIP + MP group were injected intravenously VIP 5 nmol/kg,MP 3 mg/kg and VIP 5 nmoL/kg + MP 3 mg/kg after LPS 10 mg/kg injection.The control group injected normal saline intravenously instead of LPS.The rats were sacrificed at 6 h and 24 h after injection and the intestine samples were collected.Pathological changes of the intestine were observed by microscopy.RT-PCR was used to detect the intestinal TLR2 mRNA and TLR4 mRNA expressions.Results Intestinal mucosa showed edema or necrotic change with structure of the microvilli disappeared after LPS injection.The inestinal lesions in VIP,MP and VIP + MP groups were milder than LPS group.At 6 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions were significantly up-regulated in LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:1.14 ±0.38,1.17 ±0.42,1.16 ±0.41,0.92 ± 0.29;TLR4 mRNA 1.21 ±0.18,1.04 ± 0.38,1.11 ± 0.34,1.01 ± 0.20) compared with the control group (0.32 ± 0.20,0.24 ± 0.17) (P ＜ 0.01).But there was no significant difference between LPS group,LPS + VIP group,LPS + MP group and LPS + VIP + MP group (P ＞ 0.05).At 24 h after LPS injection,TLR2 mRNA and TLR4 mRNA expressions in LPS + VIP group,LPS + MP group and LPS + VIP + MP group (TLR2 mRNA:0.63 ± 0.12,0.59 ± 0.13,0.52 ±0.19;TLR4 mRNA 0.67 ±0.09,0.64 ±0.09,0.51 ±0.13) were significantly lower than LPS group (1.04 ± 0.38,0.82 ±0.18) (P ＜0.01) (P ＜0.05).Conclusion VIP and/or MP can mitigate intestinal injury induced by LPS shock.The gastrointestinal protection of VIP and glucocorticoids were related to downregulation signaling TLR2 mRNA and TLR4 mRNA expression.But VIP/MP and VIP + MP have no significant effect on expression of intestinal TLR2/4 mRNA until 24 h after LPS shock.

Objective To evaluate the values of CD64 expression in diagnosis of infected patients referred to intensive care unit.Method Sixty febrile children referred to the hospital intensive care unit from 2009.11 to 2010.03 were enrolled for a retrospective study.Fever was defined as a body temperature reaching 38℃ or higher with specifically bacterial infection or highly suspected with bacterial infection or viral infection.There were 28 patients with bacterial infection and 32 with viral infection.The non-infectious diseases such as juvenile rheumatoid arthritis and Kawasaki disease were excluded.The controls were 50 healthy children asking for physical examination.On admission,CD64 were measured by using flow cytometry,and blood routine examination,ESR,PCT,blood cultures and sputum cultures were simultaneously detected in all febrile patients.Data were statistically analyzed by using SAS 16.0 software.Data are given as means±SE.Categorical variables were analyzed using X2 test and continuous variables were compared by applying paired 1-tailed t test,Significance level was set at less than 0.05.Results of them,57.1%bacterial infection patients and 71.9%viral infection patients contracted pneumonia.CD64 in bacterial infection patients、viral infection patients and the subjects of control group were(12.6±9.7),(5.4±2.42)and (2.9±0.77),respectively.The CD64 in the bacterial infection patients were significantly higher than those in the virus infection patients(F=11.002,P=0.004).Conclusions CD64 in infected children referred to a hospital intensive care unit can be clearly distinguished between bacterial infections and viral infections, providing an important guidance and a flexible strategy for clinical treatment and determine the timing of withdrawal.

Objective To explore the clinical characteristics of critically ill children infected with pseudomonas aeruginosa(PA) and PA antibiotics resistance in pediatric intensive care unit (PICU).Methods Case records of children with PA infection admitted to PICU in children′s hospital affiliated to Shanghai Jiaotong University from Jan 2007 to Dec 2009 were reviewed for clinical characteristics,case fatality rate,prognosis and drug resistance.Results (1) Clinical features:12 cases were community-acquired infection and 46 cases were hospital-acquired infections in 58 cases.On the same period,hospital-wide surveillance obtained PA 232 strains,PICU obtained PA 112,the ratio was 48.3%.Twelve cases died and total mortality was 20.7%.The mortality was significantly difference between community-acquired infections (5 cases,41.6%)and hospital-acquired infections (7 cases,15.2%)(P<0.05).The main symptom of children with community-acquired infections were intestinal infection (5 cases) and sepsis (5 cases).The children had acute onset and developed to shock and multiple organ dysfunction syndrome rapidly.Laboratory examination revealed the white blood cell normal (7/12) and decreased in 5 cases (5/12).The value of C-reactive protein was increased significantly,and the concentration of blood endotoxin were also increased.In the hospital-acquired PA infection cases,the main symptom was respiratory abnormal (38 cases),worsen primary disease,extended staying days in PICU.(2)Drug resistance analysis:112 PA,69.8% of ceftazidime-resistant,72.8% of the imipenem-resistant.Conclusion There is significant difference of the clinical features between PA community-acquired infection and hospital-acquired infection.The former is mostly primary infections with high fatality rate.PA hospital-acquired infection has become an important pathogen of nosocomial infection in PICU.And it is important to prevent PA infection caused by a long term broad-spectrum antibiotics application and invasive medical procedures.

Objective To investigate the effect and safety of sildenafil on persistent pulmonary hypertension of the newborn (PPHN). Also compared the effect of sildenafil with tolazoline and milrione. Methods Forty five neonates with PPHN were recruited from January 2005 through October 2008 in NICU, 25 males and 20 females. The median gestational age was (39.3 + 2.4) weeks, the median birthweight was (3 114.0±10.2) g, and the median age were (13.0±0.8) hours. The patients were randomly assigned to receive sildenafil, tolazoline and milrione therapy. The pulmonary artery pressure (PAP) was measured by echocardiography. Results Thirty patients were cured, 6 patients were improved and 9 patients were of no effect. The total effective rate was 80%. There was no statistical difference among sildenafil, tolazoline and milrione. The PAP decreased when the patients were treated with sildenafil, tolazoline and milrione. No side effects happened in all patients treated with the three drugs. Conclusions Sildenafil is an effective and safe drug to reduce PAP of PPHN and it also help to improve cardiac function.

Objective To investigate the changes of epithelial neutrophil activating peptide-78 (ENA-78) in the serum of patients with critical illness,and to analyze the relationship between the severity and prognosis.Methods Prospective case-control study was performed,and 42 cases of critically ill patients admitted to Pediatric Intensive Care Unit,Children's Hospital Affiliated to Shanghai Jiaotong University from Sep.to Nov.2013 were selected as critically ill group,blood specimens were collected within 24 hours and 7 days after their admission.Another 42 cases of blood samples were collected during physical examinations in this hospital as control group.The severity of critically ill patients were graded by Pediatric Critical Illness Score (PICS) and Pediatric Risk of Score Mortality (PRISM) Ⅲ,and the serum ENA-78 was measured by double antibody sandwich enzyme-linked immunoassay.Results 1.The level of ENA-78 in the control group was (0.44 ± 0.28) ng/L; ENA-78 in acute phase and recovery phase of critically ill group were (2.85 ± 0.89)ng/L and (1.00 ± 0.64)ng/L,respectively,there were statistical differences between control group and critically ill group,acute phase group and recovery phase group (all P =0.000).2.The negative correlation was observed between ENA-78 concentration and PCIS score(r =-0.724,P =0.000).ENA-78 in PRISM Ⅲ ≥ 10 group was significantly higher than that in PRISM Ⅲ＜ 10 group(P =0.000).The ENA-78 between death group and the survival group was significantly different(P =0.000).3.ENA-78 in patients with severe infection was higher than that in the non-infectious cases(P =0.000).4.With the organ dysfunction expanded ENA-78 rose accordingly,and the difference was statistically significant (P =0.000).Conclusions The level of ENA-78 is different in critically ill patients in children.It can provide reference of assessing the severity of disease and predicting prognosis by determing the ENA-78 level.

Objective To evaluate the value of urine neutrophil gelatinase-associated lipocalin (uNGAL) to early diagnose acute kidney injury(AKI) of critically ill children in PICU.Methods Eighty critically ill children at PICU of Children's Hospital Affiliated to Shanghai Jiaotong University were enrolled in this study from April to June 2013.They were continuously observed for 72 hours.According to pediatric RIFLE criteria for diagnosis of AKI,patients were divided into AKI group (15 cases) or non-AKI group (65 cases).Additionally,according to sepsis diagnostic criteria,patients were divided into sepsis group (31 cases) or non-sepsis group (49 cases).The levels of serum creatinine and uNGAL were measured within 6th hour,24th hour,48th hour,72th hour after admitted to PICU.The differences of uNGAL levels between AKI and non-AKI groups,sepsis without AKI and non-sepsis non-AKI groups,sepsis merged AKI and sepsis without AKI groups were analysed.The sensitivity and specificity of uNGAL and serum creatinine for diagnosis of AKI at 48th hour were evaluated by ROC curve.Results Thirteen cases of eighty children developed to AKI after admitted to PICU.(1)The uNGAL levels [M(QR),ng/ml] in AKI group within 6th hour,at 24th hour,48th hour,72th hour were 863.00 (696.00),700.50 (580.00),365.50 (285.00),289.50 (319.30),respectively,which were significantly higher than those in non-AKI group [20.00 (106.00),20.00 (85.30),20.00(101.00),20.00(36.00)] (P ＜0.01).(2)The uNGAL levels in new developed group were much higher than those in non-AKI group at each time point.The comparision of serum creatinine at 48th hour was statistic difference.(3)The uNGAL levels rised at early stage in sepsis without AKI group and down to normal gradually after 48th hour.(4)The uNGAL levels continued increasing in sepsis merged AKI group,and had significant differences comparing with sepsis without AKI group(P ＜ 0.01).(5) The areas under ROC curve of uNGAL and serum creatinine at 48th hour were 0.902(95％ CI:0.801 ～ 1.004) and 0.801 (95％ CI:0.768 ～ 0.981),respectively.Conclusion The level of uNGAL has earlier increase for 24 to 48 hours than that of serum creatinine in critically ill children,and it can also reflect the severity of AKI.Therefore it can be used as an early diagnostic biomarker for AKI in PICU.

Objective To explore the protective effect of rnicroRNA (miRNA)-155 inhibitor on interleukin-1 receptor-associated kinase (IRAK)-1 mRNA and IRAK-4 mRNA in endotoximia induced liver injury in mice.Methods One hundred and twenty male BALB/c mice were randomly divided into healthy control group(n =40),endotoximia group (n =40) and miRNA-155 inhibitor group (n =40).Each group were divided into 6 h,12 h,24 h,48 h subgroups,each of which consisted of 10 mice.The mice in miRNA-155 inhibitor group were administered with miRNA-155 inhibitor[80 mg(kg ·d)] via tail vein injection before lipopolysaccharide (LPS) administration while the other two groups treated with normal saline,following 24 hours,model of endotoximia mice was produced by injection of LPS intraperitoneally.At 6 h,12 h,24 h,48 h after LPS exposure,the experimental mice were sacrificed and the liver tissue samples were collected.Histopathological changes,the expression of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,tumor necrosis factor (TNF)-α,IL-1,IL-10 were detected.Results LPS exposure resulted in increase of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,TNF-α,IL-1 and IL-10 in both endotoximia group and miRNA-155 inhibitor group compared to the control group,miRNA-155 inhibitor resulted in decrease of miRNA-155,IRAK-1 mRNA,IRAK-4 mRNA,TNF-α,IL-1 and IL-10 in miRNA-155 inhibitor group compared to the endotoximia group.There were significant differences of miRNA-155 expression at 12 h,24 h,48 h after LPS exposure among 3 groups (P ＜ 0.05).Both IRAK-1 mRNA and IRAK-4 mRNA showed significant differences at 12 h,24 h,48 h.Turning to inflammation factors,differences were found among 3 groups at all time points (P ＜ 0.05).At light-scope,there was improvement in sepsis associated liver injury in miRNA-155 inhibitor group compared to endotoximia group.Conclusion miRNA-155 inhibitor administration appears to down regulate IRAK-1 mRNA and IRAK-4 mRNA expression and further deduce the excessive inflammatory and anti-inflammatory reaction,which may alleviate liver injury in endotoximia mice.