Objective:To compare the clinical features and outcomes of cancer-related and non-cancer-related sepsis in children who were admitted pediatric intensive care unit (PICU).Methods:The clinical history of patients with sepsis, who were admitted to PICU in Shanghai Children′s Hospital, Shanghai Jiao Tong University from August 2016 to July 2019, were retrospectively reviewed. A total of 768 patients were divided into the cancer-related sepsis group (135 cases) and the non-cancer-related sepsis group (633 cases). The patients in the cancer-related group were further categorized into three subgroups including hematological malignancy (80 cases), solid tumor (43 cases) and hemophagocytic lymphohistiocytosis (HLH) (12 cases). The variables of clinical features, laboratory tests, pathogens, management strategies and in-hospital mortality were compared between the two groups by student t test, Mann-Whitney U test or Chi-square test. Results:The patients with cancer-related sepsis accounted for 17.6% of all patients (135/768). Regarding the site of initial infection, the incidence of gastrointestinal infection (43.0% (58/135) vs. 28.6% (181/633), χ 2=10.718, P=0.001), blood stream infection (29.6% (40/135) vs. 17.1% (108/633), χ 2=11.297, P=0.001) and skin and soft tissue infection (22.2% (30/135) vs. 4.1% (26/633), χ 2=54.013, P<0.01) were higher in the patients with cancer-related sepsis than in those with non-cancer-related sepsis. On first PICU admission, the levels of hemoglobin (71 (61, 83) vs. 106 (92, 116) g/L, Z=13.594, P<0.01), white blood cell (1.4 (0.3, 5.2) vs. 9.8 (5.8, 15.1)×10 9/L, Z=11.213, P<0.01), platelet count (51 (15, 121) vs. 286 (192, 384)×10 9/L, Z=13.336, P<0.01), CD19 +cells (0.106 (0.008, 0.274) vs. 0.325 (0.224, 0.454), Z=6.555, P<0.01), and neutrophil (0.449 (0.170, 0.730) vs. 0.683 (0.537, 0.800), Z=5.974, P<0.01) were significantly lower in patients with cancer-related sepsis; however, the levels of C-reactive protein (82 (25, 155) vs. 36 (11, 86) mg/L, Z=-5.257, P<0.01), procalcitonin (1.5 (0.3, 12.0) vs. 0.8 (0.2, 4.0) μg/L, Z=-2.767, P=0.006), CD8 +cells (0.329 (0.253, 0.514) vs. 0.209 (0.156, 0.275), Z=-5.699, P<0.01), interleukin (IL) -6 (0.1 (0.1, 522.4) vs. 0.1 (0.1, 0.1) ng/L, Z=-2.747, P=0.006), IL-8 (0.1 (0.1, 177.0) vs. 0.1 (0.1, 4.5) ng/L, Z=-2.087, P=0.037), and IL-10 (0.1 (0.1, 42.7) vs. 0.1 (0.1, 6.6) ng/L, Z=-2.148, P=0.032) were significantly higher in patients with cancer-related sepsis. Similarly, the rate of continuous renal replacement therapy (CRRT) (34.8% (47/135) vs. 16.9% (107/633), χ 2=26.267, P<0.01) and the use of intravenous immunoglobulin (IVIG) (83.0% (112/135) vs. 66.2% (419/633), χ 2=14.667, P<0.01) were significantly higher in cancer-related sepsis group. Moreover, the incidence of co-infection with fungi was also higher in cancer-related sepsis group (14.1% (19/135) vs. 0.5%(3/633), χ 2=73.965, P<0.01), and so was the number of multiple organ dysfunction (3 (2, 5) vs. 2 (1, 3), Z=-6.988, P<0.01). Finally, the in-hospital mortality rate of cancer-related sepsis and non-cancer-related sepsis were 36.3% (49/135) and 9.3% (59/633), respectively, also significantly different (χ 2=67.000, P<0.01). There was no difference in the in-hospital mortality among children with hematologic tumors, solid tumors and HLH (35.0% (28/80) vs. 32.6% (14/43) vs. 7/12, χ 2=2.838, P=0.242). Conclusions:The site of initial infection, inflammatory markers on PICU admission, and co-infection pathogen during hospitalization are different between patients with cancer-related sepsis and non-cancer-related sepsis. Besides, the in-hospital mortality of cancer-related sepsis is about 4-fold that of non-cancer-related sepsis. The monitoring of clinical features and organ dysfunction, and timely treatment are crucial for cancer-related sepsis.

Objective: To explore the therapeutic role of bedside continuous blood purification(CBP) in children with severe acute pancreatitis(SAP). Method: The clinical and laboratory data of 11 children with SAP who were admitted to Pediatric Intensive Care Unit (PICU) of Shanghai Children′s Hospital from June 2013 to May 2016 were analyzed, including using pediatric critical illness score (PCIS) and pediatric risk of score mortality (PRISM)-Ⅲ score to assessing the severity of the disease.For those patients with severe organ dysfunction, CBP treatment was used when conventional therapy was not efficient.The evolution and prognosis of the disease were observed and analyzed.The measurement data were analyzed by Wilcoxon signed rank test. Result: From June 2013 to May 2016, 11 cases with SAP were treated in PICU, of whom 7 cases had combined multiple organ dysfunction syndrome(MODS). After conservative treatment for 12-24 h, 6 cases with SAP deteriorated aggressively and were treated with CBP.PRISMA and PRISMA flex machines were used with Gambro PRISMA filter, and continuous venovenous hemodiafiltration(CVVHDF) or high volume hemofiltration (HVHF) were chosen as the therapy model.All 6 SAP patients survived after bedside CBP treatment(the median time spent on CBP were 48.5(48.0, 55.5) h). The serum concentration of amylase before and after the CBP treatment were respectively 675(495, 1 334)vs.176(136, 246) U/L, lipase 551(385, 1 075)vs.143(117, 185) U/L, CRP 168(125, 192) vs. 67(28, 87) mg/L, and inflammatory cytokines(TNF alpha 67.2(51.0, 72.9)vs. 22.6(19.3, 31.0) ng/L, IL-6 47.8(35.2, 88.4)vs. 23.6(20.3, 42.9) ng/L, IL-10 21.3(16.8, 23.9)vs. 35.6(26.5, 38.6) ng/L), which were obviously improved after CBP treatment(all P<0.05). And after CBP treatment, partial pressure of oxygen(PaO₂)/fraction of inspiration O₂(FiO₂) (192(101, 208)and 240(207, 267) mmHg, 1 mmHg=0.133 kPa), MAP (58.3(56.3, 62.5) and 83.3(74.0, 87.4) mmHg) and PCIS scores (66(62.5, 72)and 92(89, 94) scores) were higher (all P<0.05). Conclusion CBP in critically ill with SAP can rapidly reduce blood amylase and lipase, help to keep the stable internal environment, block the systemic inflammatory response, improve the organ functions and maintain the fluid balance.CBP treatment may be a potential therapy in children with SAP.

Objective To evaluate the value of noninvasive monitoring of pulmonary arterial pressure in the children with severe pneumonia and respiratory failure.Methods A prospective study was adopted to investigate 69 patients who suffered from severe pneumonia and respiratory failure in Pediatric Intensive Care Unit in Shanghai Children's Hospital from June 2013 to December 2013 were involved in this study,except for heart disease.The pulmonary arterial pressure (PAP) and cardiac function were monitored by using bedside color doppler ultrasound cardiogram,such as PAP,cardiac index (CI),left ventricle ejection fraction(LEFT),and heart early diastolic filling velocity maximum/heart late diastolic filling velocity maximum (E/A ratio).They were divided into 2 groups according to PAP,one group as pulmonary arterial pressure normal group,the other group as pulmonary arterial hypertension(PAH) group,and the impact of the PAP on the prognosis and mechanical ventilation was assessed.Milrinone[0.5 μg/(kg · min)] were given the patients who were combined with pulmonary hypertension,and the PAP and cardiac function before using Milrinone and 24 h,48 h and 72 h after giving medicine was observed.Results Among 69 cases,40 cases were male and 29 cases were female,age ranging from 2 months to 12 years old,and the weight range was (14.3 ± 8.9) kg.The pediatric critical illness score(PICS) was 70.5 ± 9.6,and the pediatric risk of score m ortality Ⅲ was 13.5 ± 5.0.Among 69 cases,46 cases had pulmonary arterial hypertension,38 cases of them experienced mechanical ventilation,and 9 cases died.Among 23 cases who had no pulmonary arterial hypertension,only 8 cases experienced mechanical ventilation.There was a significant difference in the mechanical ventilation rate and mortality between two groups(x2 =15.78,P ＜0.0l ; x2 =5.18,P ＜ 0.05).The mechanical ventilation time was longer in pulmonary arterial hypertension group (t =3.89,P ＜0.01).PAP was (58.23 ±5.44) mmHg(1 mmHg =0.133 kPa),(49.10 ±4.69) mmHg,(42.53 ±4.54)mmHg and(35.63 ±4.78) mmHg respectively before and after using Milrinone 24 h,48 h and 72 h in 46 cases with pulmonary arterial hypertension,and the pressure decreased significantly after using medicine (F =67.11,P ＜ 0.01).There was no significant difference in CI,LVEF and E/A(all P ＞0.05).However,9 cases of them did not show any response to Milrinone,and in the end they couldn't live without mechanical ventilation,they died.Conclusions Noninvasive pulmonary arterial pressure monitoring could be beneficial in judging patient's condition and assessing prognosis of children with severe pneumonia and respiratory failure,and milrinone could decrease PAP.

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.

Objective To explore the clinical features and diagnostic methods of tuberculosis infection in PICU,and improve the understanding of tuberculosis.Methods We analysed the clinical features and diagnostic methods of severe tubercle bacillus infectious diseases in PICU from Jan 2009 to Dec 2012.Severity of disease was graded by pediatric critical illness score.The diagnosis of the pulmonary tuberculosis was in accord with the diagnostic criteria of paediatric pulmonary tuberculosis established by Chinese Medical Association paediatrics branch.And the diagnosis of tuberculosis meningitis and tuberculosis peritonitis based on the clinical physical examination,laboratory examination and pathologic finding.Results Among 22 cases enrolled in this study,totally 16 cases were pulmonary tuberculosis,6 cases were extrapulmonary tuberculosis,and 3 cases were tuberculosis meningitis.The clinical feature of severe tuberculosis infection in PICU was accompanying with one or multiple organ dysfunction besides tuberculosis infection symptom,among them,respiratory dysfunction occurred in 16 cases,cardiovascular dysfunction was observed in 2 cases,and central nervous system dysfunction was found in 3 cases,even 1 patient experienced cardiovascular system dysfunction,respiratory disorder as well as gastrointestinal system dysfunction simultaneously.Sixteen cases of pulmonary tubercle bacillus infection manifested respiratory failure besides fever,cough,shortness of breath and tuberculosis toxicosis symptom,2 cases of them developed into acute respiratory distress syndrome,8 cases needed mechanical ventilation.Two cases of pericardial effusion presented cardiac tamponade.The level of adenosine deaminase elevated in 12 cases,and the positive result of enzyme-linked immunospot assay for tubercle bacillius was observed in 14 cases.Conclusion It is very important to be aware of that severe tubercle bacillus infection exist in critically ill patients admitted in PICU,measuring the level of adenosine deaminase and taking enzyme-linked immunospot assay for tubercle bacillius test are important accessory examination for tuberculosis diagnosis in children.

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.

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.

OBJECTIVETo assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO₂] in evaluation of disease severity and prognosis in children with septic shock who already had central venous oxygen saturation (ScvO₂) higher than 70% after early resuscitation.

METHODIn this prospective study, 48 septic shock children seen in Shanghai Children's Hospital, Shanghai Jiao Tong University were enrolled from Jun 2012 to May 2014. 36(75.0%) were male, 12 (25.0%) were female, the average age was (31.9 ± 24.5) months. The critically ill patients with septic shock were treated to achieve ScvO₂greater than 70% depending on early goal-directed therapy (EGDT). All patients were divided into two groups, based on P(cv-a)CO₂, low P(cv-a)CO₂group with P(cv-a)CO₂< 6 mmHg (1 mmHg = 0.133 kPa) and high P(cv-a)CO₂group with P(cv-a)CO₂≥ 6 mmHg. The parameters of hemodynamics including mean blood pressure (MAP), heart rate (HR), central venous pressure (CVP), perfusion-related parameters [ScvO₂, P(cv-a)CO₂, serum lactate (Lac), Lac clearance rate], pediatric critical illness score, PRISMIII score, and 28 days in-hospital mortality were recorded for all patients.

RESULTOf the 48 cases with septic shock whose ScvO₂was higher than 70%, 17 patients (35.4%) had high P(cv-a)CO₂( ≥ 6 mmHg) and 31 (65.6%) had lower P(cv-a)CO₂(<6 mmHg). There were no significant differences between the 2 groups of patients in age, PRISMIII score and PCIS (P > 0.05 ), but Lac and P(cv-a)CO₂values were significantly different ( P < 0.05). Low P(cv-a) CO₂group patients had lower 28 days mortality than high P(cv-a) CO₂group[11/17 vs. 32.3% (10/31), P < 0.05]; 24 h after resuscitation, compared with high P(cv-a) CO₂group, low P(cv-a) CO₂group patients had lower Lac values [(2.0 ± 1.3) vs.( 2.7 ± 1.2) mmol/L, P < 0.05]. Low P(cv-a) CO₂group patients had shorter duration of vasoactive drugs use [(16 ± 14) vs. (44 ± 21)h, P < 0.05], 24 h Lac clearance rate was significantly higher for low P(cv-a) CO₂group than for high P(cv-a) CO₂group[ (31 ± 10) % vs. (26 ± 6)%, P < 0.05].

CONCLUSIONWhen ScvO₂> 70% was achieved after early resuscitation in septic shock children, P(cv-a) CO₂is a sensitive biomarker to assess tissue perfusion, and high P(cv-a) CO₂group patients had poor outcome.

Arterial Pressure ; Blood Gas Analysis ; Carbon Dioxide ; blood ; Central Venous Pressure ; Child, Preschool ; China ; Critical Illness ; Female ; Heart Rate ; Hemodynamics ; Hospital Mortality ; Humans ; Infant ; Lactic Acid ; blood ; Male ; Oximetry ; Prognosis ; Prospective Studies ; Resuscitation ; Severity of Illness Index ; Shock, Septic ; blood ; therapy

Objective To study the changes of P-selectin and E-selectin in pediatric patients with critical illness ,and analyze their relationship with the severity and prognosis of diseases.Methods Forprospective study,42 critically ill patients admitted in pediatric intensive care unit (PICU ) from September,2012 to March,2013 as critically ill group were enrolled,and blood specimens were collected with 24 hours after admission.Another 42 cases blood samples were collected from children's physical examination as control group.The severity of the critically ill patients were evaluated by Pediatric Critical illness Score (PICS)and Pediatric risk of score mortality (PRISM)-III.The levels of serum P-selectin and serum E-selectin were measured by double antibody sandwich enzyme-linked immunoassay (ABC-ELISA). Results P-selectin and E-selectin in control group children and critically ill patients group were (37.23 ± 8.99)ng/mL,(36.24 ±17.82)ng/mL,and (107.24 ±35.53)ng/mL,(114.93 ±40.17)ng/mL, respectively.There were statistical differences between two groups (P=0.000).The levels of P-selectin and E-selectin in acute phase were higher than that of levels in recovery phase in critically ill group (P =0.000).Negative correlation was observed between P-selectin concentration and the PCIS score (r =-0.673,P=0.000),as well as E-selectin (r=-0.548,P=0.000).P-selectin level and E-selectin level based upon PRISMⅢ≥10 group were significantly higher than they in PRISMⅢ <10 group (P=0.003,P=0.014).In critically ill children,the differences in P-selectin,E-selectin were significant higher in death patients (P=0.003;P =0.000).Compared with the non-sepsis illness group,the level of P-selectin and E-selectin in the severe sepsis patients were significantly higher (P =0.04,P =0.025 ). Conclusions The levels of P-selectin and E-selectin are closely related to the severity and prognosis in critically ill children.Measuring the level of P-selectin and E-selectin could be used as a judegment the severity and to understand pathological physiological process.