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中国小儿急救医学
中国小儿急救医学

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中国小儿急救医学/Journal Chinese Pediatric Emergency MedicineCSTPCD
查看更多>>中华医学会主办。本刊是国内儿科领域中惟一一本反映危重症急救方面的国家级儿科专业学术期刊。为中国科技论文统计源期刊，中国科技类核心期刊。杂志主要读者群为全国各级医院的儿科医生，尤其是从事儿科危重症急救方面的临床医生。杂志的栏目有专题讨论、论著、 临床应用研究、综述、讲座、儿科急诊室、 继续医学教育园地、 教学查房、临床病理（例）讨论、短篇报道等。本刊现已被国际权威检索系统俄罗斯《文摘杂志》、美国《化学文摘》、波兰《哥白尼索引》、美国《乌利希国际期刊指南》列为来源期刊 ，并被国内《中国科技论文与引文数据库》（CSTPCD）等多家数据库收录。
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    《2024年国际共识标准：儿童脓毒症和脓毒性休克》解读

    应佳云刘婷彦周文彬周鹤恬...
    1-5页
    查看更多>>摘要：2024年新年伊始，《2024年国际共识标准：儿童脓毒症和脓毒性休克》（简称"2024年儿童共识"）发布。本文对2024年版儿童共识提出的脓毒症及脓毒性休克标准进行解读，并比较2005版儿童共识及2016版成人指南的诊断标准。2024年儿童共识更新并评估了儿童脓毒症和脓毒性休克的标准，采用新型菲尼克斯脓毒症评分（Phoenix Sepsis Score, PSS）（包括呼吸、心血管、凝血和神经系统的功能障碍）至少2分，可以确定疑似感染的儿童[<18岁（排除围生期住院的新生儿及早产儿（<37周）]是否存在脓毒症；脓毒性休克定义为PSS心血管评分至少1分的脓毒症。该标准不再使用全身炎症反应综合征，也取消了严重脓毒症诊断，并提出出现远隔感染部位器官功能障碍的儿童脓毒症患者存在更高的死亡风险。2024年儿童共识新标准强调了脓毒症相关的器官损伤，可促进全球疾病流行病学数据的统一收集，为持续管理提供了基础，从而改善患儿结局，并为未来的研究提供信息。

    儿童脓毒症脓毒性休克菲尼克斯脓毒症评分

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    百尺竿头三十载，风华正茂仍少年

    钱素云
    321页
    查看更多>>摘要：从1994到2024，脚踏实地、竿头直上的30年。从年少青涩到羽翼丰满，矢志不渝、激流勇进的30年。专家笔谈，聚焦临床难点、热点深入展开，缜密、全面、开卷有益。论著，基于问题深入研究，求真、探索、引领创新。综述，着眼最新进展深入探讨，系统、整合、与时俱进。临床应用研究，基于实践经验深入介绍，务实、客观、条理分明。
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    全身免疫炎症系数、预后营养指数对早产儿早发型败血症的预测价值

    庞玉冰仝子凡刘文强徐艳...
    327-332页
    查看更多>>摘要：目的 探讨全身免疫炎症系数（SII）及预后营养指数（PNI）对早产儿早发型败血症（EOS）的预测能力。 方法 选取2019年1月至2022年12月于徐州医科大学附属医院出生，并于1 h内转入新生儿重症监护室，符合EOS诊断标准的28～32周早产儿作为EOS组，1∶1匹配同期住院的非感染早产儿作为对照组，收集相关资料，比较两组间临床资料、血常规相关指标、C-反应蛋白（CRP）、血清白蛋白水平（ALB）及SII、PNI的差异，采用Logistic回归分析及绘制受试者工作特征（ROC）曲线评价SII及PNI预测EOS的能力。 结果 与对照组相比，EOS组患儿1 min及5 min Apgar评分更低，剖宫产娩出及气管插管的比例更高，化脓性脑膜炎、支气管肺发育不良、早产儿视网膜病变及颅内出血的发生率更高；EOS组血常规WBC、ALB、SII和PNI水平较对照组降低，CRP升高；差异均有统计学意义（P<0.05）。多因素Logistic回归分析显示，气管插管、CRP、SII及PNI是EOS的独立影响因素（P<0.05）。ROC曲线分析显示，SII、PNI、CRP、SII联合PNI的曲线下面积分别为0.808（95%CI 0.730~0.886）、0.792（95%CI 0.718~0.865）、0.633（95%CI 0.541~0.725）、0.866（95%CI 0.803~0.929），灵敏度分别为74.3%、64.3%、42.9%、78.6%，特异度分别为88.6%、82.9%、81.4%、90.0%，SII、PNI、CRP的临界值分别为221.36、38.65、0.80 mg/L。 结论 SII、PNI对早产儿EOS具有一定的预测价值，且两者联合预测效能更强。 Objective To explore the predictive ability of systemic immune-inflammation index（SII）and prognostic nutrition index（PNI）for early-onset sepsis in preterm infants. Methods Seventy preterm infants of 28 to 32 weeks，who were born in the Affiliated Hospital of Xuzhou Medical University from January 2019 to December 2022, and transferred to neonatal intensive care unit within 1 h conforming to EOS diagnostic criteria were selected as the EOS group，and 1∶1 matched non-infected preterm infants hospitalized during the same period were selected as control group.Relevant data were collected to compare the differences regarding clinical data，blood routine indicators，C-reactive protein（CRP），serum albumin levels（ALB），SII and PNI between two groups.The ability of SII and PNI to predict EOS was evaluated by Logistic regression analysis and receiver operating characteristic（ROC）curve. Results Compared with control group,the EOS group had lower 1-minute and 5-minute Apgar scores,higher rates of cesarean section delivery and tracheal intubation,as well as higher rates of suppurative meningitis,bronchopulmonary dysplasia,retinopathy of prematurity and intracranial hemorrhage.The levels of blood routine parameters,ALB,SII and PNI in the EOS group were lower than those in control group,while CRP was increased.The differences were all statistically significant（P<0.05）.Multivariate Logistic regression analysis showed that tracheal intubation，CRP，SII and PNI were independently influential factors of EOS（P<0.05）.ROC curve analysis showed that the areas under curve of SII，PNI，CRP and SII combined with PNI were 0.808（95%CI 0.730-0.886），0.792（95%CI 0.718-0.865），0.633（95%CI 0.541-0.725）and 0.866（95%CI 0.803-0.929），the sensitivity were 74.3%，64.3%，42.9%，78.6%，and the specificity were 88.6%，82.9%，81.4%，90.0%,respectively.The cut-off values of SII，PNI and CRP were 221.36，38.65 and 0.80 mg/L,respectively. Conclusion SII and PNI have a certain predictive value for EOS in preterm infants，and their combined diagnosis efficiency is more stronger.

    全身免疫炎症系数预后营养指数早产儿早发型败血症

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    儿童嗜麦芽窄食单胞菌感染临床特征分析

    周媛婕沈楠杜白露黄卫春...
    333-336页
    查看更多>>摘要：目的 了解儿童嗜麦芽窄食单胞菌（SMA）感染的特征。 方法 回顾性队列研究选取2018年1月至2023年6月就诊于上海儿童医学中心诊断SMA感染的患儿为研究对象，分析患儿的各类临床特征。根据最终治疗的转归分为存活组和死亡组，并比较两组患儿的临床特征。 结果 共70例患儿纳入研究，其中女23例，男47例，发病年龄9.0（3.0，12.6）岁。65例（92.9%）患儿系血液系统及实体肿瘤患儿，其中24例（34.3%）患儿进行了骨髓造血干细胞移植，18例（25.7%）进行了嵌合抗原受体T细胞免疫疗法（CAR-T）。SMA感染部位40例（57.1%）为呼吸道感染，19例（27.1%）为血流感染，11例（15.7%）为软组织感染。感染前33例（47.1%）患儿接受糖皮质激素治疗，63例（90.0%）接受碳青霉烯类药物。最终39例（55.7%）患儿好转出院，31例死亡，病死率达44.3%。培养出的SMA对米诺环素、左氧氟沙星、复方新诺明、头孢哌酮/舒巴坦的敏感率分别为100.0%、98.1%、96.2%、94.0%。对比存活组患儿，死亡组患儿年龄更大[11.9（8.4，13.8）岁比6.3（2.1，10.0）岁]，感染前住院时间及干细胞移植后时间更长[28（23，46）d比25（16,34）d，140（93，221）d比24（12，49）d]，感染前入住ICU、感染前使用激素、接受CAR-T治疗及基础疾病系淋巴瘤的患儿比例更高[26例（83.9%）比15例（38.46%），22例（71.0%）比11例（28.2%），13例（41.9%）比5例（12.8%），11例（35.5%）比3例（7.7%）],差异均有统计学意义（P<0.05）。 结论 SMA感染主要出现在恶性肿瘤、免疫受损、应用广谱抗生素的患儿中。在儿童患者中，SMA对复方新诺明、米诺环素、左氧氟沙星及头孢哌酮/舒巴坦保持着良好的敏感率。SMA感染后病死率高，发病年龄大、较长的感染前住院时间、干细胞移植后时间长、感染前入住ICU、感染前使用激素、接受CAR-T治疗及基础疾病系淋巴瘤可能与感染后死亡有关。 Objective To understand the clinical characteristics of stenotrophomonas maltophilia（SMA）infections in pediatric patients. Methods This was a retrospective observational study.The children diagnosed with SMA infections between January 2018 and June 2023 at Shanghai Children's Medical Center were selected as the study population.The clinical characteristics of patients were analyzed.According to the outcome,the patients were categorized into survival and death groups to compare the clinical characteristics. Results A total of 70 patients were included in the study,including 23 females and 47 males,with an onset age of 9.0 (3.0,12.6) years old.Sixty-five (92.9%) patients had underlying malignancies，primarily hematologic and solid tumors,of which 24(34.3%) cases underwent bone marrow hematopoietic stem cell transplantation,and 18(25.7%) cases underwent chimeric antigen receptor T cell immunotherapy (CAR-T).Forty (57.1%) cases of SMA infection sites were respiratory infections,19 (27.1%) cases were bloodstream infections,and 11 (15.7%) cases were soft tissue infections.Prior to infection，33（47.14%）patients were treated with glucocorticoids and 63（90.0%）patients with carbapenems.Eventually，39（55.7%）patients were discharged,while 31 patients died,with a mortality rate of 44.3%.Minocycline（100.0%），levofloxacin（98.1%），co-trimoxazole（96.2%），and cefoperazone/sulbactam（94.0%）showed high sensitivity rates to SMA.Compared with the survival group,the death group had a younger age [11.9 (8.4,13.8) years vs.6.3 (2.1,10.0) years],longer hospitalization before infection and duration after stem cell transplantation [28 (23,46) d vs.25 (16,34) d,140 (93，221) d vs.24 (12,49) d],and a higher proportion of pre-infection ICU admission,pre-infection glucocorticoids usage,receiving CAR-T treatment and lymphoma as the underlying disease [26 (83.9%) cases vs.15 (38.46%) cases,22 (71.0%) cases vs.11 (28.2%) cases,13 (41.9%) cases vs.5(12.8%) cases,11（35.5%）cases vs.3（7.7%）cases],and the differences were all statistically significant (P<0.05). Conclusion SMA infection pose a serious risk to pediatric patients with malignancies,compromised immune systems and exposured to broad-spectrum antibiotics.SMA maintains excellent sensitivity to compound sulfamethoxazole，minocycline，levofloxacin，and cefoperazone/sulbactam in pediatric patients.The mortality rate of SMA infection is very high，with longer pre-infection hospitalization，pre-infection ICU admission，pre-infection glucocorticoids usage，older onset age，longer duration after stem cell transplantation,receiving CAR-T treatment and lymphoma as the underlying disease possibly associated with post infection mortality

    儿童嗜麦芽窄食单胞菌临床特征

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    脓毒症患儿外周血T淋巴细胞减数分裂重组11同源物A表达水平变化研究

    韦芷欣梁秀安杨志勇林楠...
    337-341页
    查看更多>>摘要：目的 分析脓毒症患儿T淋巴细胞的减数分裂重组11同源物A（MRE11A）表达，初步探讨MRE11A对脓毒症T淋巴细胞功能的影响。 方法 选取2021年12月至2022年4月广西医科大学第一附属医院PICU住院的脓毒症患儿24例作为脓毒症组；同期本院门诊体检的24例健康儿童作为对照组。收集两组患儿性别、年龄，脓毒症组收集有创机械通气时间、实验室检查指标及住院时间等，采集入住PICU 24 h内外周血标本，对照组在研究期间同期采集外周血。采用流式细胞技术检测两组外周血T淋巴细胞胞质MRE11A，对比两组之间MRE11A表达阳性的细胞比例和表达量（用平均荧光强度表示）。 结果 脓毒症组、对照组各24例；脓毒症组男11例，女13例，中位年龄32.50（19.00，132.75）个月；对照组男14例，女10例，中位年龄57.50（33.75，102.25）个月；两组年龄和性别比较差异无统计学意义（均P>0.05）。脓毒症组MRE11A+CD4+T淋巴细胞比例低于对照组[3.59（2.29，8.87）%比99.90（99.03，100.00）%，Z=-5.961，P<0.001]，CD4+T淋巴细胞的MRE11A表达量低于对照组[1 663.00（1 557.00，1 777.00）比5 689.00（4 415.25，9 567.00），Z=-5.939，P<0.001]；脓毒症组MRE11A+CD8+T淋巴细胞比例低于对照组[3.85（1.87，9.58）%比92.15（76.70，96.40）%，Z=-5.856，P<0.001],CD8+T淋巴细胞的MRE11A表达量低于对照组[1 921.50（1 680.00，2 217.00）比4 165.00（2 894.00，9 122.00），Z=-5.083，P<0.001]。 结论 MRE11A在脓毒症患儿T淋巴细胞胞质表达降低，可能影响了T淋巴细胞功能。 Objective To analyze the expression of meiotic recombination 11 homolog A（MRE11A）in T lymphocytes of children with sepsis，and to explore the effect of MRE11A on the function of T lymphocytes in sepsis. Methods . Twenty-four children with sepsis hospitalized in PICU at the First Affiliated Hospital of Guangxi Medical University from December 2021 to April 2022 were selected as sepsis group.During the same period,24 healthy children who underwent outpatient physical examination in our hospital were selected as control group.The gender and age of two groups were collected,and the duration of invasive mechanical ventilation,laboratory examination index and hospitalization time were collected in sepsis group.The peripheral blood samples of sepsis group were collected within 24 hours of admission to PICU,and peripheral blood samples of control group were collected during the study period.Flow cytometry was used to detect the cytoplasmic MRE11A of peripheral blood T lymphocytes in two groups,and the proportion as well as expression of MRE11A positive cells between two groups were compared (expressed by mean fluorescence intensity) Results There were 24 cases in sepsis group,including 11 males and 13 females,with a median age of 32.50 (19.00,132.75) months.There were 24 cases in control group,including 14 males and 10 females,with a median age of 57.50 (33.75,102.25) months.There were no significant differences in gender and age between two groups (all P>0.05).The proportion of MRE11A+CD4+T lymphocytes in sepsis group was lower than that in control group[3.59（2.29，8.87）% vs.99.90（99.03，100.00）%，Z=-5.961，P<0.001 ].The expression of MRE11A in CD4+T lymphocytes in sepsis group was lower than that in control group[1 663.00（1 557.00，1 777.00）vs.5 689.00（4 415.25，9 567.00），Z=-5.939，P<0.001].The proportion of MRE11A+CD8+T lymphocytes in sepsis group was lower than that in control group[3.85（1.87，9.58）% vs.92.15（76.70，96.40）%，Z=-5.856，P<0.001].The expression of MRE11A in CD8+ T lymphocytes in sepsis group was lower than that in control group[1 921.50（1 680.00，2 217.00）vs.4 165.00（2 894.00，9 122.00），Z=-5.083，P<0.001]. Conclusion The expression level of MRE11A in the cytoplasm of T lymphocytes in children with sepsis was decreased,which may affect the function of T lymphocytes.

    减数分裂重组11同源物A脓毒症T淋巴细胞儿童

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    儿童Montgomery T管置入术后PICU管理及随访分析

    杜岩谭乐恬刘盼杜俐佳...
    342-348页
    查看更多>>摘要：目的 通过对置入Montgomery T管重症患儿的临床情况进行分析及随访，总结T管置入术后PICU监护管理的经验及T管在重症儿童应用的效果。 方法 对2019年4月至2021年12月复旦大学附属儿科医院收治的7例Montgomery T管置入术后患儿的病因、临床特点、并发症、ICU住院情况及长期随访情况进行分析，结合临床经验，对T管在病情危重、需要接受长期机械通气患儿中的应用加以阐述。 结果 研究期间纳入了7例置入T管术后入住PICU的患儿，男3例，女4例，年龄9~75个月，5例患儿接受机械通气治疗。其中喉先天性畸形5例，气管食管瘘1例，喉乳头状瘤1例。主要并发症为痰液堵塞、感染及肉芽增生。1例患儿出现分泌物堵塞死亡，其余患儿均成功撤离T管，T管最长留滞时间367 d，5例患儿拔除T管后出现声嘶。6例存活患儿出院后生活质量较术前提高，均恢复经口进食，门诊随访未诉吞咽困难及误吸,但均合并营养不良。 结论 Montgomery T管是一种安全可靠的气道支架，可用于气道重塑以及维持介入术后气道的通畅；对于儿童重症患者，做好早期气道廓清及抗感染等管理至关重要。 Objective To analyze the clinical situation of critically ill children with Montgomery T-tube，aiming to summarize the characteristics of T-tube application in pediatric and the experience of postoperative airway management in PICU. Methods The etiology，clinical characteristics，complications and ICU admissions of patients with Montgomery T-tube admitted to the Pediatric Hospital of Fudan University from April 2019 to December 2021 were analyzed，and the application of T-tube in patients with critical conditions requiring long-term mechanical ventilation was described in the light of clinical experience. Results During the study period,seven children were admitted to the PICU after T-tube insertion,including three males and four females,aged 9~75 months.Five children received mechanical ventilation.Among them,there were five cases with congenital laryngeal malformations,one case with tracheoesophageal fistula,and one case with laryngeal papilloma.The main complications were sputum blockage,infection,and granulation proliferation.One child died of secretion blockage,while the other children were successfully evacuated from the T-tube.The longest retention time of the T-tube was 367 days.Five patients experienced hoarseness after removing the T-tube,and upon re-examination with fiberoptic bronchoscopy,no recurrence of subglottic stenosis was observed.There was no respiratory distress or wheezing,and there were no abnormalities observed during regular outpatient follow-up after discharge.After discharge,the quality of life of the six surviving children improved compared to preoperative,and they all resumed oral feeding.There were no complaints of swallowing difficulties or aspiration during outpatient follow-up.But they were all combined with malnutrition. Conclusion The Montgomery T-tube is a secure and dependable airway stent utilized for airway remodeling and the maintenance of airway patency following interventional surgery.For critically ill children,early management of airway clearance and infection prevention are imperative.

    儿童蒙哥马利T管气道管理机械通气

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    机械循环支持在儿童暴发性心肌炎中的应用进展

    姜嘉琳韩波林楠
    349-352页
    查看更多>>摘要：暴发性心肌炎是由多种病因引起的严重的心脏炎性疾病，起病隐匿、恶化急骤，早期临床症状不典型，患儿极易出现顽固性心源性休克、心力衰竭及致死性心律失常，病死率高。近年来，机械循环支持（MCS）的发展为急危重症患儿的抢救带来曙光，但由于技术发展、经济水平等因素限制，儿童MCS只能在少数医院开展，发展阶段远落后于成人。本文从不同种类MCS入手，重点阐述MCS在儿童暴发性心肌炎中的应用进展，为临床进一步开展相应技术提供理论支持。 Fulminant myocarditis is a severe heart inflammatory disease caused by a variety of causes，which are so insidious and deteriorative rapidly，with atypical early clinical symptoms，and that the patients are prone to obstinately cardiogenic shock，heart failure and fatal arrhythmia with high mortality.In recent years，the development of mechanical circulatory support（MCS）has brought light to the rescue of critically ill children.Due to factors such as technological limits and economic level，children MCS can only be carried out in a minority of superior medical establishment，which developmental stage is still lagging far behind that of adults.This review summarized the recent progress of MCS in children with fulminant myocarditis from the perspective of the multifold types of MCS for providing theoretical support for further clinical improment.

    暴发性心肌炎机械循环支持儿童

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    高流量鼻导管吸氧在儿童哮喘急性发作中的应用

    周惠赵睿泽张景威刘文...
    353-357页
    查看更多>>摘要：高流量鼻导管吸氧（HFNC），作为新型氧疗和呼吸支持方式，已经成功地用于毛细支气管炎等儿科疾病。近年来，HFNC也越来越多地用于支气管哮喘急性发作的治疗，但缺少儿科的临床应用实践指南。本文对HFNC用于儿童支气管哮喘急性发作的效果评估、应用时机、并发症及参数调整等方面进行综述，以进一步指导临床应用。 High flow nasal cannula（HFNC）is a novel oxygen therapy developed in recent years，and has been successfully used in pediatric diseases such as bronchiolitis and pneumonia.Although there has been a lack of clinical application guidelines in pediatrics，it has been increasingly applied to the treatment of exacerbations of bronchial asthma.This review focused on efficacy，application timing，complications and parameters adjustment of HFNC in children with asthma exacerbation，so as to further guide the clinical use.

    高流量鼻导管吸氧哮喘急性发作儿童

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    肺血管扩张药物治疗支气管肺发育不良相关性肺动脉高压的研究进展

    白晓婷梅花林楠
    358-362页
    查看更多>>摘要：支气管肺发育不良是极早产儿最常见的慢性肺疾病。部分重度支气管肺发育不良常合并肺动脉高压，以肺泡弥散性损害、肺血管重构异常为特征，继而导致肺血管阻力增加而发生右心衰竭，严重影响早产儿体格及神经发育。肺血管扩张药物可通过一氧化氮途径、内皮素途径及前列腺素途径降低肺动脉压力。本文就肺血管扩张药物在支气管肺发育不良相关性肺动脉高压治疗情况进行综述。 Bronchopulmonary dysplasia is the most common chronic lung disease in very preterm infants.Some severe bronchopulmonary dysplasia is often combined with pulmonary hypertension，characterized by diffuse alveolar damage and abnormal pulmonary vascular remodeling，followed by right heart failure due to increased pulmonary vascular resistance.It seriously affects the physical and neurological development of preterm infants.Pulmonary vasodilator drugs can reduce pulmonary artery pressure through nitric oxide pathway，endothelin pathway and prostaglandin pathway.This review summarized the pulmonary vasodilator drugs in the treatment of pulmonary hypertension associated with bronchopulmonary dysplasia.

    肺血管扩张药物肺动脉高压支气管肺发育不良早产儿

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    中和抗体治疗儿童重症呼吸道合胞病毒感染的研究进展

    高媛李玖军林楠
    363-366页
    查看更多>>摘要：呼吸道合胞病毒（RSV）是幼儿严重下呼吸道感染的主要病原体之一，RSV感染有较高的住院率和病死率。目前尚未报道有特异性抗RSV疗法。RSV主要由其表面F、G蛋白起到黏附及侵袭宿主细胞的作用。针对具有中和位点的F蛋白及G蛋白的相关单克隆抗体成为研发热点。本文对基于中和抗体抗RSV的机制、相关预防及治疗手段进行综述。 Respiratory syncytial virus（RSV）is the leading cause of severe lower respiratory tract infections in young children，with a high rate of hospitalization and mortality.Specific anti-RSV therapies have not been reported.The structure of RSV is such that it is mainly F and G proteins in the surface that act as adhesion and invade the host cells.Therefore，monoclonal antibodies against F and G proteins with neutralization sites are currently being developed. This review summarized the mechanism, prevention and treatment of RSV based on neutralizing antibody.

    中和抗体呼吸道合胞病毒病毒性肺炎重症儿童

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