摘要：
目的 探讨影响脓毒症休克早产儿预后的危险因素. 方法 收集2014年2月至2017年1月陆军总医院附属八一儿童医院新生儿重症监护病房(neonatal intensive care unit, NICU)收治的114例脓毒症休克的早产患儿的临床资料进行回顾性分析.依据临床结局,将这些患儿分为治愈组和死亡组(包括治疗无效和放弃治疗出院后死亡者).分析2组患儿的一般临床资料、围产期危险因素、临床特征及预后,以及相关并发症的发生情况.以t检验、Wilcoxon非参数检验、χ2检验(或Fisher精确概率法)对2组数据进行统计学分析.采用Logistic回归分析疾病预后的影响因素.采用受试者工作特性(receiver operating characteristic,ROC)曲线评价指标的预测价值.结果 (1)114例患儿中,治愈组87例(76.3%),死亡组27例(23.7%).(2)死亡组羊水污染、贫血和血小板减少(指血小板计数＜100×109/L)的比例,以及C-反应蛋白(C-reactive protein, CRP)水平均高于治愈组[29.6%(8/27)与8.1%(7/87),χ2=6.618;22.2%(6/27)与5.9%(5/87), χ2=4.665;59.3%(16/27)与23.3%(20/87),χ2=12.546;36.0(1.0~80.0)与7.5(1.0~25.0)mg/L, Z=2.400];血红蛋白水平低于治愈组[(122.2±43.3)与(140.5±34.4)g/L,t=2.260](P值均＜0.05).(3)死亡组动脉导管未闭、肺出血和凝血功能障碍患儿的比例高于治愈组[81.5%(22/27)与 60.9%(53/87),χ2=3.871;37.0%(10/27)与 12.6%(11/87),χ2=6.616;48.2%(13/27)与20.7%(18/87),χ2=7.847;P值均＜0.05].(4)多因素Logistic回归分析发现,羊水污染、凝血功能障碍、动脉导管未闭和C-反应蛋白水平是新生儿预后不良的危险因素(P值均＜0.05).(5)114例患儿共分离出77例病原体(治愈组66例,死亡组11例).2组革兰阳性菌、革兰阴性菌和真菌的构成比分别为37.9%(25/66)与3/11、37.9%(25/66)与6/11,以及24.2%(16/66)与2/11.2组病原体类型分布差异无统计学意义.(6)CRP的ROC曲线下面积为0.649(P=0.024).当CRP为31 mg/L时,预测脓毒症休克早产儿不良结局的敏感度和特异度分别是0.802和0.556,约登指数为 0.358;血小板减少的 ROC 曲线下面积为 0.708(P ＜ 0.001),当血小板水平为94×109/L时,预测脓毒症休克早产儿不良结局的敏感度和特异度分别是0.767和0.593,约登指数为0.360. 结论 羊水污染、动脉导管未闭、凝血功能障碍和升高的CRP水平是脓毒症休克早产儿发生死亡的危险因素.血小板减少和CRP持续升高对脓毒症休克早产儿预后有预测价值.%Objective To investigate the risk factors affecting the prognosis of preterm infants with septic shock. Methods A retrospective study was conducted to analyze the clinical data of 114 preterm children with septic shock admitted to the Neonatal Intensive Care Unit (NICU) of the PLA Army General Hospital from February 2014 to January 2017. According to the outcomes, these cases were divided into two groups, the cured group and the death group (including those died after ineffective treatment and withdrawal of treatment). Clinical data including the general clinical data, perinatal risk factors, clinical features and prognosis of the two groups of children, as well as the occurrence of related complications were statistically analyzed by t-test, Wilcoxon nonparametric test, Chi-square test or Fisher's exact probability method. Logistic regression was used to analyze the factors influencing the prognosis. Predictive values of the indicators were evaluated using receiver operating characteristic (ROC) curve. Results (1) Among the 114 patients, 87(76.3%) were cured and 27(23.7%) were dead. (2) In the death group, there were more infants complicated with amniotic fluid pollution, anemia and thrombocytopenia (platelet count <100×109/L) and the C-reactive protein (CRP) levels were higher than those in the cured group [29.6% (8/27) vs 8.1% (7/87), χ2=6.618; 22.2% (6/27) vs 5.9% (5/87), χ2=4.665; 59.3% (16/27) vs 23.3% (20/87), χ2=12.546; 36.0 (1.0-80.0) mg/L vs 7.5 (1.0-25.0) mg/L, Z=2.400], while the hemoglobin level was lower [(122.2±43.3) g/L vs (140.5±34.4) g/L, t=2.260] (all P<0.05). (3) The percentages of infants with patent ductus arteriosus, pulmonary hemorrhage and coagulopathy in the death group were higher than those in the cured group [81.5% (22/27) vs 60.9% (53/87), χ2=3.871; 37.0% (10/27) vs 12.6% (11/87), χ2=6.616;48.2% (13/27) vs 20.7% (18/87), χ2=7.847; all P<0.05]. (4) Multivariate logistic regression analysis showed that amniotic fluid contamination, coagulopathy, patent ductus arteriosus and CRP level were risk factors for poor prognosis in neonates (all P<0.05). (5) A total of 77 pathogens were isolated from the 114 infants with 66 in the cured group and 11 in the death group. Pathogens of Gram-positive and Gram-negative bacteria and fungi in the cured and death groups accounted for 37.9% (25/66) vs 3/11, 37.9% (25/66) vs 6/11, and 24.2% (16/66) vs 2/11, respectively. No significant difference in pathogen distribution was observed between the two groups. (6) The area under the ROC curve of CRP was 0.649 (P=0.024). When the cut-off value of CRP was set at 31 mg/L, the sensitivity and specificity for predicting adverse outcomes in preterm infants with septic shock were 0.802 and 0.556, respectively, and the Yoden index was 0.358. The area under the ROC curve of thrombocytopenia was 0.708 (P<0.001). When the platelet level was set at 94×109/L, its sensitivity and specificity were 0.767 and 0.593, respectively, and the Yoden index was 0.360. Conclusions Amniotic fluid contamination, patent ductus arteriosus, coagulopathy and elevated CRP are important risk factors for death in preterm infants with septic shock. Thrombocytopenia and persistently elevated CRP has predictive values for the prognosis of preterm infants with sepsis shock.
