BackgroundGreen neutrophilic inclusions (GNIs) are rare cytoplasmic inclusions in peripheral blood smears, historically associated with acute liver failure and high mortality. Recent evidence suggests that GNIs may also occur in other critical illnesses; however, reports in pediatric populations remain scarce. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome, but GNIs have not been previously described in patients with HLH.Case presentationWe report a 9-year-and-5-month-old female with Epstein-Barr virus-related hemophagocytic lymphohistiocytosis (EBV-HLH) in whom GNIs were identified in peripheral blood neutrophils during her clinical course. The patient presented with persistent fever, progressive cytopenias, hyperferritinemia, hemophagocytosis on bone marrow aspirate, and markedly elevated cytokines. Despite intensive supportive care, including continuous renal replacement therapy and plasma exchange, her condition deteriorated rapidly. On hospital day 6, GNIs were identified in her peripheral blood neutrophils. She died of multiorgan dysfunction on hospital day 8.ConclusionThis is the first report of GNIs in a patient with EBV-HLH. GNIs expand the clinical spectrum of EBV-HLH and may serve as an ominous prognostic marker in pediatric patients.

BackgroundIn recent years, accidental injury has emerged as a leading cause of mortality in the pediatric population. Such trauma frequently induces severe damage to parenchymal organs as a result of significant external mechanical force. In severe cases, death may occur rapidly when impaired cardiopulmonary function cannot be adequately sustained. Extracorporeal membrane oxygenation (ECMO) plays a critical role in supporting these patients. However, the selection of an anticoagulation strategy remains a decisive factor influencing clinical outcomes. This study aims to evaluate the comparative efficacy of regional anticoagulation using nafamostat mesilate vs. systemic anticoagulation with unfractionated heparin in pediatric patients with trauma undergoing extracorporeal membrane oxygenation (ECMO) support.MethodsIn this study, 40 patients hospitalized due to severe trauma and received ECMO assistance were selected as the research subjects. According to the anticoagulation protocol, the patients were divided into the nafamostat mesilate group and the unfractionated heparin (UFH) group. Demographic data, hematological profiles, and coagulation parameters were systematically compared at baseline, 24, and 72 h after admission in patients receiving ECMO support. Clinical outcomes were evaluated based on the following criteria: transfusion requirements, use of coagulation-related agents, incidence of complications, and successful removal. The SPSS 21.0 statistical software was utilized for data statistics.ResultsA total of 40 patients were enrolled in this study, 24 cases in the nafamostat mesilate group and 16 cases in the UFH group. There was no statistically significant difference in characteristics of blood cell classification and coagulation-related laboratory parameters at admission. Compared with the nafamostat mesilate group, the UFH group exhibited a higher rate of new-onset active bleeding, circuit thrombosis, and this difference was statistically significant (P < 0.05). In the UFH group, the incidence of mandatory anticoagulant discontinuation was significantly higher than that in the nafamostat mesilate group, attributable to a greater volume of active bleeding. Subgroup analysis patients who underwent surgery, new-onset active bleeding occurred in two of eight patients in the nafamostat mesilate group, with no interruption of anticoagulation, whereas severe new-onset active bleeding occurred in six of nine patients in the UFH group, requiring discontinuation of anticoagulation (all P < 0.05).ConclusionIn trauma patients during ECMO support, nafamostat mesilate achieves effective anticoagulation comparable to unfractionated heparin (UFH) while significantly lowering the risk of bleeding.

BackgroundInfluenza co-infection with Staphylococcus aureus (S. aureus) can cause rapidly fatal necrotizing pneumonia, septic shock, and acute respiratory distress syndrome (ARDS) in children. Although methicillin-resistant S. aureus is often highlighted, community-acquired methicillin-susceptible S. aureus (CA-MSSA) can also produce equally severe disease.Case presentationWe report an 8-year-4-month-old male with influenza A (H3N2) who developed septic shock and refractory hypoxemia, requiring immediate intubation. Due to persisting respiratory failure despite maximal ventilation, veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated on day 1. Metagenomic next-generation sequencing identified S. aureus as the dominant pathogen, and bronchoalveolar lavage fluid culture later confirmed MSSA. After vancomycin failed clinically, the regimen was switched to linezolid. However, on day 15 of linezolid therapy, the patient developed severe linezolid-induced lactic acidosis (LILA), which resolved within 3 days of stopping the drug. The clinical course was further complicated by pneumothorax and multidrug-resistant organism superinfections. After 54 days of intensive care, the patient was discharged in good condition.ConclusionThis case underscores that during influenza seasons, early empirical anti-staphylococcal therapy should be considered in children with rapidly progressive pneumonia and shock, even when CA-MSSA is suspected. Additionally, routine lactate monitoring is critical during linezolid therapy to enable prompt recognition and management of life-threatening LILA.

Background:The prognosis of acute respiratory distress syndrome (ARDS) varies with inflammatory responses. ARDS patients with a hyperinflammatory phenotype usually have worse alveolar epithelial injury and vascular endothelial injury than those carrying a hypoinflammatory phenotype. Activated neutrophils recruited and migrated in the lung tissue are responsible for stimulating the progression of ARDS. Interleukin-8 (IL-8), as an inflammatory factor, further aggravates lung damage in ARDS. Methods:This was a retrospective study involving 135 ARDS children admitted in two pediatric hospitals in northwest China. They were either classified into mild, moderate and severe groups based on the oxygenation index (OI) or oxygenation saturation index (OSI) within 4-h invasive mechanical ventilation on admission, or the survival and non-survival groups based on the 28-day mortality. Demographic and clinical data were analyzed. Risk factors for the prognosis of PARDS were identified by logistic regression. The correlation of IL-8 level with the identified risk factors was analyzed. Prognostic potential of IL-8 was determined by plotting the receiver operating characteristic (ROC) curves. Results:IL-8, RAGE, Ang-2, ICAM-1 and SP-D were independent risk factors for the mortality of PARDS. They were significantly higher in the non-survival group than the survival group, showing a potential in predicting mortality in PARDS, especially in the combination (P < 0.05). IL-8 was positively correlated with RAGE, Ang-2, ICAM-1 and SP-D in children with ARDS (P < 0.05). Conclusion:IL-8 is overexpressed in children with ARDS, showing a prognostic potential particularly in combination with RAGE, Ang-2, ICAM-1 and SP-D in PARDS.

Hemophagocytic lymphohistiocytosis (HLH) secondary to Pneumocystis jirovecii pneumonia (PJP) is extremely rare in children. We present the case of a 10-year-old girl with a history of idiopathic thrombocytopenic purpura (ITP) on long-term oral prednisone, who was admitted for progressive fever, cough, and dyspnea. Metagenomic next-generation sequencing of blood and bronchoalveolar lavage fluid confirmed PJP. Despite targeted antifungal therapy and respiratory support, she developed persistent high-grade fever, pancytopenia, hyperferritinemia, hypofibrinogenemia, and hemophagocytosis on bone marrow aspirate by day 10, meeting diagnostic criteria for HLH. Genetic testing was declined by the parents. Management included dexamethasone, continuous renal replacement therapy, and plasmapheresis. Unfortunately, her condition deteriorated, and she was discharged upon parental request on day 22, succumbing on the same day. To our knowledge, this is the first reported pediatric case of HLH secondary to PJP in China. This case highlights that in children with PJP—especially those on immunosuppressive therapy—the development of persistent fever and cytopenia should prompt immediate evaluation for secondary HLH to enable timely intervention.

Objective:To analyze the clinical effectiveness of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in rescuing children with severe pulmonary contusion.Methods:A retrospective analysis was conducted on the clinical data of four children with severe pulmonary contusion who were treated with VV-ECMO in the pediatric intensive care unit of Xi'an Children's Hospital from April 2021 to December 2024. The general data, laboratory indicators within 24 hours after admission, imaging features, bronchoscopic findings, diagnostic and treatment processes, as well as therapeutic outcomes of the children were analyzed.Results:All four pediatric cases were male, aged 4 years and 9 months, 6 years and 5 months, 8 years and 10 months, and 9 years and 7 months, respectively. One case resulted from a high-altitude fall and three from traffic accidents, all presenting with multiple fractures. All four cases progressed to dyspnea within 1-4 hours post-injury and received endotracheal intubation with invasive ventilator support within 2-5 hours. Three cases exhibited tachycardia upon admission and were treated with norepinephrine, all four cases presented with fine moist rales in the lungs. Imaging studies revealed diffuse exudative changes in all four cases. Bronchoscopy identified diffuse pulmonary hemorrhage, with one case additionally showing rupture of the right intermediate bronchus. Conventional mechanical ventilation failed to correct oxygenation in all cases, prompting initiation of VV-ECMO therapy within 8-22 hours post-injury. One case underwent right thoracic exploration under ECMO support. Following treatment, all four cases demonstrated gradual reduction in bloody airway secretions, resolution of pulmonary exudative changes on imaging, and absence of hemorrhage on bronchoscopy. They were successfully weaned off ECMO and ultimately discharged as cured.Conclusions:Severe pulmonary contusion rapidly leads to respiratory distress, requiring ventilator-assisted ventilation within hours of injury. When conventional ventilator support is ineffective, ECMO can be life-saving, with timely intervention yielding favorable prognosis.

ABSTRACT:Background: Pediatric sepsis is a life-threatening condition, with extremely high incidence and mortality among critically ill children worldwide. Patients with septic shock are susceptible to intestinal complications due to altered blood flow distribution, and these complications often correlate directly with a poor prognosis. Early detection of low perfusion and appropriate resuscitation are critical components in the management of patients experiencing shock. Nevertheless, significant debate persists regarding the comparative value of various resuscitation targets. While central venous oxygen saturation (ScvO2) monitoring is frequently advocated, it remains a subject of scrutiny. All pathophysiological mechanisms are intricately linked to cellular hypoxia and energy metabolism, which is why metabolic-related biomarkers, particularly lactate and lactate clearance rate, are highly regarded by critical care experts. Nonetheless, limited research has been conducted on the association between markers of circulatory shock and metabolic disorders in critically ill patients particularly in the field of pediatrics. Physiological indicators, particularly those associated with cell energy metabolism, have shown potentials in predicting sepsis and septic shock. Methods: This was a retrospective study. A total of 63 patients, comprising 30 males and 33 females, who developed septic shock secondary to pediatric primary peritonitis, were admitted to the Intensive Care Department of the Children's Hospital Affiliated to Xi'an Jiaotong University and the Pediatric Intensive Care Unit of Gansu Provincial Maternity and Child-Care Hospital between December 2016 and December 2021. Based on the primary outcome of 28-day all-cause mortality, patients were assigned into the survival group and nonsurvival group. Demographic and clinical data were compared. Risk factors for the prognosis of septic shock secondary to pediatric primary peritonitis were identified by logistic regression, and their potentials in predicting the 28-day survival were assessed by the receiver operating characteristic and Kaplan-Meier survival curves. Results: Among the 63 eligible patients with septic shock secondary to pediatric primary peritonitis, 47 survived. In comparison to the survival group, the nonsurvival group showed significantly higher proportions of mechanical ventilation, surgical intervention, and use of vasoactive drugs, procalcitonin, activated partial thromboplastin time, respiratory quotient (RQ), lactate (Lac), the Pediatric Sequential Organ Failure Assessment score, and the Pediatric Risk of Mortality III score, but lower platelet count, fibrinogen, and mean arterial pressure (all P's < 0.05). RQ (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.41, 3.22; P < 0.05) and Lac (OR, 2.01; 95% CI, 1.15, 3.21; P < 0.05) were independent prognostic factors for septic shock secondary to pediatric primary peritonitis. Their combination (RQ < 1.6 + Lac < 4 mmol/L) achieved a better accuracy in predicting the 28-day cumulative survival. Conclusion: RQ combined with Lac offers an excellent performance in predicting mortality of septic shock secondary to pediatric primary peritonitis.

Background: In Asia, Hanta virus (HTNV) results in severe hemorrhagic fever with renal syndrome (HFRS). The efficacy of sivelestat in treating children with HTNV-induced HFRS remains unclear. Methods: An ambispective cohort study was performed on children diagnosed with HFRS and hospitalized at the Children's Hospital Affiliated to Xi'an Jiaotong University from August 2018 to 2023. Patients who received neutrophil elastin-inhibitor infusion between August 2019 and August 2023 were assigned to the sivelestat group, while patients who did not were assigned to the control group. The independent sample t test was used for inter-group analysis. The Chi-square test and Fisher's exact probability test were used for categorical variables. Spearman correlation test was used to evaluate the correlation between two sets of continuous variables. Kaplan -Meier survival curve and Log -Rank test was used to evaluate the difference in cumulative probability of survival between the two groups. Results: No significant differences were observed between the two groups in gender, age, contact history, body mass index, HFRS severity, clinical indexes at admission. Compared to the control group, the sivelestat group exhibited a significant decrease in the interleukin-8 level at 48 h (28.5 +/- 3 vs 34.5 +/- 3.5) and 72 h (21.3 +/- 4.5 vs 31.5 +/- 5.6) ( P <0.05), as well as the ICAM-1 level at 48 h (553 +/- 122 vs 784 +/- 187) and 72 h (452 +/- 130 vs 623 +/- 85) ( P <0.05). The concentration of VCAM-1 in the sivelestat group exhibited a consistent downward trend. Moreover, the level of VCAM-1 was significantly lower than that in the control group at 24 h (1760 +/- 289 vs 2180 +/- 445), 48 h (1450 +/- 441 vs 1890 +/- 267), and 72 h (1149 +/- 338 vs 1500 +/- 396) ( P <0.05). Kaplan -Meier curve analysis revealed a statistically significant difference in the cumulative probability of survival between two groups (P = 0.041). In the secondary outcomes, the sivelestat group demonstrated a decrease in the utilization rate of mechanical ventilation and continuous renal replacement therapy (CRRT). Conclusion: Sivelestat may suppress neutrophil-mediated inflammatory response to reduce endothelial and organ damage, and improve clinical outcomes in children with severe hemorrhagic fever and renal syndrome.

患儿，男，1月20天，以"咳嗽2 d，抽搐1次"入西安市儿童医院。2 d前患儿接触"感冒父亲"后出现咳嗽，为阵发性连声咳嗽，有痰不易咳出，不伴发热，未诊治。1 d前患儿咳嗽较前加重，频次较前明显增多。5 h前患儿出现抽搐1次，表现为双眼上翻凝视，头后仰，四肢强直抖动，持续约30 s后自行缓解，为求进一步诊治，就诊于西安市儿童医院。

目的探讨静脉-动脉血二氧化碳分压差与动脉-静脉血氧含量差比值(Pv-aCO2/Ca-vO2)对儿童原发性腹膜炎相关脓毒性休克预后的预测价值。方法采用回顾性研究, 选取2016年12月至2021年12月西安交通大学附属儿童医院重症医学科收治的63例腹膜炎相关脓毒性休克患儿作为研究对象。以28 d全因病死率为主要终点事件, 根据预后将患儿分为生存组及死亡组, 统计两组基线资料及血气分析、血常规、凝血、炎症状态、危重评分等相关临床数据。对影响预后的因素进行多因素Logistic回归分析, 并通过受试者工作特征曲线(ROC曲线)对危险因素的预测性进行检验。根据各危险因素的截断值进行分层, 通过Kaplan-Meier生存曲线分析比较各组预后差异。结果共纳入63例患儿, 男性30例, 女性33例;年龄(5.6±4.0)岁;28 d死亡16例, 病死率为25.4%。生存者与死亡组间性别、年龄、体重及病原菌分布差异无统计学意义。死亡组机械通气比例、外科干预比例、血管活性药物应用比例、前降钙素原、C-反应蛋白、活化部分凝血活酶时间、血乳酸(Lac)、Pv-aCO2/Ca-vO2、儿童序贯器官衰竭评分、儿科危重症死亡危险评分Ⅲ均较存活组明显升高, 血小板计数、纤维蛋白原、平均动脉压较生存组明显降低, 差异均具有统计学意义。通过多因素Logistic回归分析筛选出Lac及Pv-aCO2/Ca-vO2为影响患儿预后的独立危险因素〔优势比(OR)和95%可信区间(95%CI)分别为2.01(1.15～3.21)、2.37(1.41～3.22), 均P<0.01〕。ROC曲线分析显示, Lac、Pv-aCO2/Ca-vO2及二者联合的曲线下面积(AUC)分别为0.745、0.876和0.923, 敏感度分别为75%、85%和88%, 特异度分别为71%、87%和91%。根据各危险因素的截断值分层, Kaplan-Meier生存曲线分析显示, Lac≥4 mmol/L组28 d累积生存率低于Lac<4 mmol/L组〔64.29%(18/28)比82.86%(29/35), P<0.05〕;Pv-aCO2/Ca-vO2≥1.6组28 d累积生存率低于Pv-aCO2/Ca-vO2<1.6组〔62.07%(18/29)比85.29%(29/34), P<0.01〕。将两个指标变量分层组合后分析显示, Pv-aCO2/Ca-vO2≥1.6且Lac≥4 mmol/L组28 d累积生存率明显低于其他3组(Log-rank检验:χ2=7.910, P=0.017)。结论早期Pv-aCO2/Ca-vO2联合Lac对原发性腹膜炎相关脓毒性休克患儿的预后具有良好的预测价值。

BackgroundHemorrhagic fever with Renal Syndrome (HFRS) is an infectious disease caused by Hantavirus with fever, hemorrhage and acute kidney injury (AKI) as clinical characteristics. The research on the etiology and pathogenesis of diseases has become a focus of attention. However, there are few related medical studies in children with HFRS. The prognosis of the children with HFRS remains to be explored.ObjectivesWe explored risk factors in children with HFRS and summarize sensitive indicators that are conducive to the prognosis of the disease.MethodsWe designed a case-control study and recruited 182 HFRS pediatric patients (2014.01-2022.08). They were divided into two groups according to the severity of disease, including the control group(158 cases with mild and moderate subgroup)and the observation group (24 cases with severe and critical subgroup). Risk factors influencing prognosis were analyzed by binary logistic regression. The cutoff value, sensitivity and specificity of the risk factors prediction were calculated by receiver operating characteristic (ROC) and Yoden index.ResultsLymphocyte subsets characteristics analysis showed that in observation group the indexes were decreased in lymphocyte, T lymphocytes (CD3)(+), helper/inducible T lymphocytes (CD4(+))/inhibition/cytotoxic T cells (CD8(+)), B lymphocytes (CD19(+)); and the elevated index was CD8(+), the difference were all significant between two groups. (P < 0.05). With death as the primary outcome, it was found that the serum CD8(+) (odds ratio [OR] 2.91, 95% confidence interval [CI] 1.65, 4.00; P < 0.01) was risk factor and significantly associated with mortality. The cutoff value of the serum CD8(+) was 845 x 10(6)/L, the sensitivity and specificity were 78.5%, 85.4%. With complications as the secondary outcomes, the serum CD8(+) (OR 2.69, 95% CI 1.15, 4.88; P < 0.01) was found to be risk factors. The cutoff of the serum CD8(+) was 690 x 10(6)/L, the sensitivity and specificity were 69.3%, 75.1% respectively.ConclusionCD8(+) may be significantly correlated with the severity and prognosis of HFRS in children.

患儿，男，5月21天，以"咳嗽8 d，尿少2 d"入院。入院8 d前患儿无明显诱因出现咳嗽，口服中成药治疗4 d，咳嗽较前加重。2日前出现尿少，当地医院完善肾功：尿素氮47.3 mmol/L，肌酐2 109 μmol/L，遂转入西安市儿童医院儿童重症医学科。

患儿，男，9岁，28 kg，因“发热伴咳嗽11 d，加重伴呼吸困难3 d”于2021年7月29日入院。11 d前患儿出现发热，体温39.5 ℃，伴轻微咳嗽，1~2声/次，当地诊所诊断为支气管肺炎，给予头孢曲松静脉滴注及布地奈德雾化治疗5 d，患儿仍有发热伴咳嗽，遂联合阿奇霉素抗感染治疗3 d，亦未见好转。3 d前咳嗽较前加重，伴呼吸困难，遂就诊于当地医院，完善胸部CT提示右侧液气胸，给予右侧胸腔闭式引流，同时予无创呼吸机辅助通气，头孢哌酮舒巴坦钠联合青霉素抗感染等治疗，呼吸困难未见改善，改为有创呼吸机辅助通气，后仍有呼吸困难，遂转入本院。入院查体：体温38.0 ℃，脉搏110 次/min，呼吸40 次/min，血压91/55 mmHg（1 mmHg=0.133 kPa），面色口唇发绀，三凹征阳性，左肺呼吸音粗，可闻及广泛痰鸣音，右肺呼吸音低，未闻及干湿啰音，余查体未见异常。入院诊断：（1）急性呼吸窘迫综合征；（2）重症肺炎。入院后给予亚胺培南西司他丁钠联合利奈唑胺抗感染，呼吸机辅助通气［AC-VC模式 FIO 2 70%，PEEP 6 cmH 2O（1 cmH 2O=0.098 kPa），RR 20 次/min，VT 90 mL，吸呼比（I∶E）1∶2］等治疗。辅助检查：血常规：白细胞（WBC）19.94×10 9/L，中性粒细胞（NE）13.27×10 9/L，淋巴细胞（LY）2.47×10 9/L，血红蛋白（Hb）93 g/L。肝肾功能、电解质、心肌酶大致正常。C反应蛋白（CRP）2.14 mg/L。降钙素原（PCT）：8.84 μg/L。曲霉菌半乳甘露聚糖、（1，3）-β-D葡聚糖、肺炎支原体抗体、HIV均阴性。体液免疫三项（IgA、IgG、IgM）、淋巴细胞（T细胞、B细胞、自然杀伤细胞）免疫分析均正常。双份血培养、深部呼吸道分泌物培养均阴性。胸部CT可见右侧液气胸，右肺膨胀不全，左肺大片状模糊影（见图1 A~C）。胸腔彩超：右侧胸腔积液，最大深度42 mm，内可见机化黏连。入院第2天行纤维支气管镜检查，左肺可见少量稀白分泌物附着，右肺中下叶可见较多白色黏稠分泌物，灌洗后送检支气管肺泡灌洗液（bronchoalveolar lavage fluid，BALF）及血液宏基因二代测序（metagenomics next-generation sequencing，mNGS），30 h后BALF mNGS回报结果：单纯疱疹病毒1型（herpes simplex virus type 1，HSV1），序列数4 495（见图2），沃氏嗜胆菌，序列数1 383（见图3）。血液mNGS结果回报：HSV1，序列数644。考虑单纯疱疹病毒1型肺炎（herpes simplex virus type 1 pneumonia，HSV1P），遂调整抗感染策略为阿昔洛韦联合头孢哌酮舒巴坦钠，治疗3 d后患儿体温正常，呼吸机参数较前下降（AC-VC模式FIO 2 45%，PEEP 5 cmH 2O，RR 20次/min，VT 90 mL，I∶E 1∶2），治疗第5 d复查胸部CT提示右肺仍可见大面积实变影（见图1 D~F），遂行第2次纤维支气管镜检查，术中右肺可见较多稀白分泌物，再次送检BALF培养阴性。抗病毒治疗2周后复查胸部CT提示双肺肺炎较前好转，右侧液气胸局部可见包裹（见图1 G~I），撤离呼吸机，改为鼻导管吸氧。抗感染治疗3周后复查胸部CT：双肺肺炎较前明显吸收、好转（见图1 J~L），复查BALF培养及mNGS均阴性，遂停用阿昔洛韦抗病毒治疗。共住院27 d后好转出院，出院后建议胸外科随诊，必要时手术治疗，但患儿并未遵嘱随访。出院后原发性免疫缺陷病相关基因筛查回报阴性。患儿治疗参数变化。见表1。

Abstract Sepsis is a leading cause of mortality for children wordwide. Some studies suggested that initial hyperlactacidemia and central venous oxygen saturation (ScvO2) are associated with mortality in sepsis. Our objective was to compare whether SCVO2-oriented resuscitation strategies and lactate kinetics oriented resuscitation strategies differ in mortality in children with septic shock. 250 children diagnosed with septic shock between January 2017 and October 2021 were enrolled in this study, and they were randomly assigned to two groups, ScvO2-oriented group (n = 125) and lactate kinetics-oriented group (n = 125). The Trial Registration Number was 20230068 and the date of registration was June 1, 2023. The primary endpoint was the 28-day mortality, and the secondary endpoints included the mechanical ventilation time, 6 h and 12 h success rate of the resuscitation, intensive care unit (ICU) and hospital stay time, the vasoactive inotropic score (VIS) and rate of arrhythmia. There were no significant differences in baseline data and 28-day mortality between the two groups. However, the norepinephrine(NE) dose was lower in the lactate kinetics-oriented group than that in the ScvO2-oriented group at both the 2nd and 3rd day. 6 h success rate of the resuscitation in the lactate kinetics-oriented group was significantly higher than that in the ScvO2 -oriented group (P = 0.037). Conclusions: Compared with the ScvO2-oriented group, the lactate kinetics-oriented group could improve the success rate of the resuscitation in the early stages of septic shock and reduce the application of catecholamine.

Objective:To investigate the related risk factors affecting the prognosis of hemorrhagic fever with renal syndrome(HFRS) in children.Methods:A retrospective study was carried out.We selected 182 pediatric patients who met the diagnostic criteria for pediatric HFRS while hospitalized in the Intensive Care Department of the Affiliated Children′s Hospital of Xi′an Jiaotong University between July 2014 and December 2021 as the research objects.The severe and critical patients were taken as the observation group(24 cases), and the mild and moderate pediatric patients were taken as the control group(158 cases). The demographic, epidemiological data and clinically relevant indicators within 8 hours of pediatric patients after admission were collected.The 28-day death was the primary endpoint.Renal failure and pulmonary edema were secondary endpoint.The differences of clinically relevant indicators between the two groups were observed.Logistic regression was used to analyze the risk factors and receiver operating characteristic(ROC) curve was used to determine the predictive efficacy of different outcome prediction models.Results:There were no statistically significant differences in age, gender, and BMI between the two groups (all P>0.05). Compared the control group with the observation group, coagulation function indicators such as activated partial thromboplastin time (APTT)[(134±21)s vs.(164±34)s], D-dimer [(6.31±3.20)mg/L vs.(12.43±5.67)mg/L], von Willebrand factor (vWF)[(352±45)μg/L vs.(465±103)μg/L], and platelet(PLT)[(87±35)×10 9/L vs.(45±24)×10 9/L], Lactate(Lac)[(2.6±1.1)mmol/L vs.(6.0±2.0)mmol/L]were different significantly(all P<0.05). Additionally, the lymphocyte characteristic analysis indicator lymphocytes [(2 749±686)×10 6/L vs.(2 374±851)×10 6/L], CD3 + [(1 821± 487)×10 6/L vs.(1 065±539)×10 6/L], CD4 + /CD8 + (1.65±0.73)vs.(1.00±0.25), CD19 + [(559±105)×10 6/L vs.(487± 133)×10 6/L]were different significantly(all P<0.05). The inflammatory index procalcitonin(PCT) [(22±15)ng/L vs.(56±21)ng/L, P<0.05]was different significantly in two groups.The rate of continuous renaly replacement therapy, ventilator-assisted ventilation, vasoactive drugs and other treatment measures increased significantly in observation group than those in control group(all P<0.05). Multivariate logistic regression analysis was performed on the included indicators.With death as the primary endpoint, Lac, CD8 + , D-dimer, vWF and PCT were significantly associated with mortality, which were risk factors for death, while PLT and CD4 + /CD8 + were protective factors.With renal failure and pulmonary edema as secondary endpoint, CD8 + , D-dimer, Lac and PCT were risk factors for secondary endpoint.ROC curve analysis showed that the sensitivity, specificity and AUC of the risk factor prediction model related to the primary endpoint variables were 77.91%, 81.22% and 0.769, and which related to secondary endpoint variables were 87.61%, 77.59% and 0.891, respectively. Conclusion:The combinations of CD8 + , D-dimer, Lac, PCT and vWF have good predictive value for poor prognosis in children with HFRS.

体外膜肺氧合(ECMO)对严重心肺功能衰竭的患者可提供强有力的循环和呼吸支持,同时也是心肺功能衰竭患者等待心肺移植期间歇期的主要体外生命支持手段.已有大量的循证医学证据肯定了ECMO在儿童急性呼吸窘迫综合征(PARDS)中的救治作用,但在其他原因导致的急性呼吸衰竭中的应用报道较少,该文就目前ECMO在儿科急性呼吸衰竭中的应用进展作一综述.

OBJECTIVE To investigate the prognostic value of the ratio of veno-arterial carbon dioxide partial pressure difference to arterio-venous oxygen content difference (Pv-aCO2/Ca-vO2) in children with primary peritonitis-related septic shock. METHODS A retrospective study was conducted. Sixty-three children with primary peritonitis-related septic shock admitted to department of intensive care unit of the Children's Hospital Affiliated to Xi'an Jiaotong University from December 2016 to December 2021 were enrolled. The 28-day all-cause mortality was the primary endpoint event. The children were divided into survival group and death group according to the prognosis. The baseline data, blood gas analysis, blood routine, coagulation, inflammatory status, critical score and other related clinical data of the two groups were statistics. The factors affecting the prognosis were analyzed by binary Logistic regression, and the predictability of risk factors were tested by the receiver operator characteristic curve (ROC curve). The risk factors were stratified according to the cut-off, Kaplan-Meier survival curve analysis compared the prognostic differences between the groups. RESULTS A total of 63 children were enrolled, including 30 males and 33 females, the average age (5.6±4.0) years old, 16 cases died in 28 days, with mortality was 25.4%. There were no significant differences in gender, age, body weight and pathogen distribution between the two groups. The proportion of mechanical ventilation, surgical intervention, vasoactive drug application, and procalcitonin, C-reactive protein, activated partial thromboplastin time, serum lactate (Lac), Pv-aCO2/Ca-vO2, pediatric sequential organ failure assessment, pediatric risk of mortality III in the death group were higher than those in the survival group. Platelet count, fibrinogen, mean arterial pressure were lower than those in the survival group, and the differences were statistically significant. Binary Logistic regression analysis showed that Lac and Pv-aCO2/Ca-vO2 were independent risk factors affecting the prognosis of children [odds ratio (OR) and 95% confidence interval (95%CI) were 2.01 (1.15-3.21), 2.37 (1.41-3.22), respectively, both P < 0.01]. ROC curve analysis showed that the area under curve (AUC) of Lac, Pv-aCO2/Ca-vO2 and their combination were 0.745, 0.876 and 0.923, the sensitivity were 75%, 85% and 88%, and the specificity were 71%, 87% and 91%, respectively. Risk factors were stratified according to cut-off, and Kaplan-Meier survival curve analysis showed that the 28-day cumulative probability of survival of Lac ≥ 4 mmol/L group was lower than that in Lac < 4 mmol/L group [64.29% (18/28) vs. 82.86% (29/35), P < 0.05]. Pv-aCO2/Ca-vO2 ≥ 1.6 group 28-day cumulative probability of survival was less than Pv-aCO2/Ca-vO2 < 1.6 group [62.07% (18/29) vs. 85.29% (29/34), P < 0.01]. After a hierarchical combination of the two sets of indicator variables, the 28-day cumulative probability of survival of Pv-aCO2/Ca-vO2 ≥ 1.6 and Lac ≥ 4 mmol/L group significantly lower than that of the other three groups (Log-rank test, χ2 = 7.910, P = 0.017). CONCLUSIONS Pv-aCO2/Ca-vO2 combined with Lac has a good predictive value for the prognosis of children with peritonitis-related septic shock.

患儿女，9岁，以“多饮、多尿、精神欠佳2个月，加重半天”于2021年9月10日入西安市儿童医院儿童内分泌科。2个月前患儿无明显诱因出现多饮、多尿，每天饮水量约2 500 mL，尿7~8次/d，每次尿量约400~500 mL，食欲增加，体质量较前减轻。同时伴有乏力，睡眠增多，双下肢浮肿，无昏迷、抽搐及意识障碍，无发热、咳嗽，无呕吐、腹泻，无腹痛，曾就诊当地中医诊所，诊断为“脾胃虚、气血不足”予口服中药调理治疗2个月，效果欠佳。6 h前患儿精神反应差，意识障碍进行性加重，伴深大呼吸，全身乏力明显，就诊于我院急诊。急查血糖：31.3 mmol/L；尿常规：葡萄糖（+++），酮体（+++），隐血（++）；血气分析：pH 7.06，二氧化碳分压（PCO 2）6 mmHg（1 mmHg=0.133 kPa），氧分压（PO 2）143 mmHg，血清钠（Na +）127 mmol/L，血清钾（K +）2. 5 mmol/L，血清钙（Ca 2+）1.31 mmol/L，碳酸氢盐（HCO 3-）< 3 mmol/L，剩余碱（BE）未测出。给予0.9%氯化钠注射液360 mL（20 mL/kg）后以“糖尿病酮症酸中毒”收入内分泌科。患儿自发病后，食欲增加，尿量增加。近2 d无大便，2个月内体质量下降3 kg。既往史：2个月前因“急性扁桃体炎"于当地医院查尿常规：葡萄糖（++++），蛋白质（+），酮体（+++），未特殊处理、未规律复查。否认“肝炎、结核”等传染病史及接触史，否认过敏、手术及外伤史。无糖尿病家族史。入院查体：体温36.3 ℃，呼吸32次/min，脉搏124次/min，血压104/56 mmHg，体质量18 kg，嗜睡，反应差，深大呼吸，营养不良貌，口周略苍白，面色口唇欠红润，重度脱水貌。皮肤弹性差。双肺呼吸音清，未闻及干湿啰音。心音有力，律齐，各瓣膜听诊区未闻及杂音。腹胀，拒按，肝脾触诊不满意，肠鸣音2次/min。双足踝及胫前轻度凹陷性浮肿。双手足及小腿下2/3温度低，毛细血管再充盈时间5 s。初步诊断：糖尿病酮症酸中毒。入内分泌科后给予补液（1/2张无糖液体）、胰岛素（0.1 U·kg －1·h －1）静脉泵入等治疗。入院后急查血气分析：pH 7.01，PCO 2 9 mmHg，PO 2 140 mmHg，Na + 132 mmol/L，K + 1.8 mmol/L，HCO 3- < 3 mmol/L，BE未测出，监测血糖28 mmol/L，入院治疗1 h后患儿呼吸急促、费力，张口呼吸，不能平卧，意识障碍进行性加重，格拉斯哥评分10分，病情危重，转入儿童重症医学科。查体：意识不清，格拉斯哥评分8分，嗜睡，反应差，深大呼吸，营养不良貌，面色口唇欠红润，重度脱水貌。皮肤弹性差。腹膨隆，叩诊鼓音，拒按，肠鸣音2次/min。双足踝及胫前轻度凹陷性浮肿。双手足及小腿下2/3温度降低，毛细血管再充盈时间5 s。复查血糖27 mmol/L，甘油三酯162 mmol/L，胆固醇21.6 mmol/L，凝血因乳糜血测不出。转入后予无创辅助通气，但呼吸困难进行性加重，遂予气管插管，有创呼吸机辅助通气，同时予补液（1/2张无糖液体），胰岛素（0.1 U·kg －1·h －1）静脉泵入，同时血浆置换（置换血浆量900 mL）治疗，10 h后该患儿血糖降至19 mmol/L，仍呈嗜睡状，轻度脱水貌，无明显深大呼吸，面色口唇欠红润，四肢末梢稍暖，毛细血管再充盈时间3 s；继续补液及胰岛素泵入治疗；但1 h后，患儿意识障碍加重，呈昏睡状，腹胀加重，肠鸣音消失，四肢发绀，四肢末梢凉，毛细血管再充盈时间5 s，血压波动于50/30 mmHg~60/40 mmHg，血气分析pH 6.81，HCO 3- 2.3 mmol/L，BE-32.8 mmol/L，酸中毒无好转，考虑存在脓毒性休克，肠穿孔可能，立即给予0.9%氯化钠注射液扩容，去甲肾上腺素升压，美罗培南、万古霉素抗感染等治疗，胃肠减压引出黄绿色含粪汁液体，急查腹部B超提示肠淤张；腹部CT提示小肠多发肠壁积气，伴门静脉积气，腹腔积液。考虑肠管坏死伴穿孔可能性大，急请普外科会诊，急诊行剖腹探查术，术中发现距回盲部约20 cm肠管及距离曲氏韧带有约10 cm肠管颜色尚可，其余肠管均已发黑伴多处穿孔，切除坏死肠管，予空肠造瘘，肠腔置16号橡胶引流管，术后禁饮食，引流管及瘘口可引出大量墨绿色分泌物，术后继续行持续床旁血液净化治疗，于术后第2天行第2次血浆置换（置换量900 mL），术后第5天撤离有创呼吸机。患儿静脉用胰岛素静泵下血糖控制尚可，5 d后开始间断予温水鼻饲，逐渐过渡为配方奶。住院第11天患儿诉下腹胀、伤口疼痛，伴发热，体温最高39.0 ℃，且易反复，查体下腹部皮肤可有握雪感，考虑皮下积气。第12天，腹部皮下积气减少，左侧腹壁出现红肿热痛，考虑腹壁感染，予拔除肠腔引流管，腹壁缝线拆除，造瘘袋贴于腹壁切口周围皮肤，保持引流通畅，伤口周围涂抹氧化锌软膏保护皮肤，治疗上继续禁食、胃肠减压，小剂量胰岛素，补液，静脉营养，美罗培南联合万古霉素抗感染。动态监测血糖、血脂，均正常；经抗感染治疗后患儿逐渐体温正常，精神反应好转，于住院第20天转入内分泌科继续静脉营养治疗，住院70 d后，患儿腹部切口愈合好，行造瘘口闭合术，术后肠道恢复良好，逐渐过度肠内营养联合静脉营养，住院90 d，好转出院。随访半年，患儿精神反应好，营养状态中等，持续静脉营养及部分肠内营养中。血糖控制良好。

目的:分析静脉-静脉体外膜肺氧合在抢救严重塑型性支气管炎患儿的临床有效性。方法:回顾性分析西安市儿童医院儿童重症医学科2021年9月至2021年11月收治的3例经静脉-静脉体外膜肺氧合抢救严重塑型性支气管炎患儿的临床资料，并对相关国内外文献进行复习。结果:3例患儿中，男2例，女1例，年龄分别为6岁7个月、3岁1个月、7岁7个月。3例患儿既往体健，无基础疾病。3例均以双向性呼吸困难伴有严重喘息为主要临床表现。3例患儿影像学均提示不同程度斑片影，同时合并肺不张，2例患儿存在气胸，1例存在纵隔积气及皮下积气。3例患儿均为社区获得性感染，主要感染病原有乙型流感病毒、人类疱疹病毒4型、肺炎支原体、肺炎链球菌、金黄色葡萄球菌等。3例入院时均存在严重呼吸困难，有创呼吸机辅助通气下呼吸困难改善不佳，氧合无改善，二氧化碳潴留进行性加重，伴意识障碍。2例入院后立即行床旁纤维支气管镜检查发现主气道塑型，取出困难，并术中出现心率下降，均行心肺复苏，复苏后氧合仍差，另外1例入院后即出现心率下降，经心肺复苏抢救后恢复自主心率，3例患儿经评估后立即行静脉-静脉体外膜肺氧合治疗。生命体征平稳后行支气管镜检查提示严重塑型性支气管炎。经治疗，3例患儿治愈出院，出院随访3个月，患儿均无任何症状，活动耐力与发病前相同，复查胸部CT均未见异常。结论:严重塑型性支气管炎疾病早期无特异性临床表现及影像学改变，病情进展迅速，很快出现呼吸衰竭，常规机械通气无效时，体外膜肺氧合可有效改善患儿预后。

破伤风是由破伤风梭状芽孢杆菌通过皮肤黏膜伤口侵入人体，在厌氧环境中繁殖并产生外毒素，引起的以全身骨骼肌持续性强直收缩及阵发性痉挛为特征的急性特异性感染 [1]，在无医疗措施干预下病死率接近100% [2,3]，即使经过积极的抢救治疗，全球范围病死率仍为30%~50% [4,5]，严重威胁患者生命。虽已有报道血液灌流 [6,7,8]及连续性肾脏替代治疗 [9]用于破伤风的救治，但我国尚未见血浆置换用于儿童破伤风的救治，现将我科应用血浆置换成功治疗儿童破伤风的临床资料报道如下，为今后此类患儿的救治提供参考。