Clinical Analysis Of Risk Factors And Prognosis Of Sepsis-associated Encephalopathy In PICU

Objectives: Sepsis-Associated Encephalopathy is a diffuse brain dysfunction caused by an immune response out of control to sepsis with the exception of the central nervous system infection and multiple organ dysfunction caused by damage to the nervous system function.SAE is one of the most common encephalopathy in PICU,and a common critical disease in pediatric.The incidence of Sepsis-Associated Encephalopathy has been reported to be 8% to 70%[1] in septic patients,and the Mortality rate is 34.48% compared with 15.38% of the single fatality rate of sepsis.Children belong to a special group.Their organs are not mature and easy to be infected.So they have a higher chance of sepsis with nervous system dysfunction.There are sufficient studies of sepsis in recent years,but the research of morbidity,mortality,risk factors of SAE in children is seldom investigated.The etiology of SAE in children remains unclear.The early brain injury is reversible by corresponding diagnosis and treatment measures.,otherwise the brain injury increases progressively and is irreversible.In the early-stage of SAE,timely medical treatment can reduce the function damage of the brain and others organs.It is important to reduce the fatality rate of SAE and improve the symptoms of patients with survival rate.We collected the data of pediatric patients with sepsis admitted in PICU,and made analysis of epidemiological characteristics such as age、sex、underlying disease、infection site 、 infection bacteria species 、 iconography 、 cerebrospinal fluid 、electroencephalogram.we tried to find the risk factors of Children with SAE and made a corresponding clinical diagnosis and treatment measures in the early stage of SAE.In addition,we analyzed EEG in Children with SAE during the hospital stay and follow-up period,and got the significance of EEG in SAE prognosis evaluation.Methods:1 We selected 112 children of sepsis from PICU of Hengshui people’s hospital covering the period between January the first 2016 and December the thirty-first 2016.All the subjects were divided into two groups: SAE-group and Non-SAE group and their onset time was within 3 days.Diagnostic standards of Sepsis refer to Children with septic shock(infectious shock)diagnosis and treatment expert consensus in 2015[2].Diagnostic standards of SAE refer to the SAE diagnostic standard proposed by papadopoulos MC et al[3].The exclusion criteria: Age>14,with hypotension、hypoglycemia、chronic liver、kidney dysfunction、cardiopulmonary cerebral recovery after operation、intracranial infection and organic disease of central nervous system and previous history、poison intoxication、use of sedative drugs and so on.2 All the cases need to be measured by PCIS Score、GCS Score、blood routine、CRP、blood culture、electrolyte、hepatic-renal function、myocardial enzyme、fasting blood-glucose、blood lipids、lactic acid、arterial blood gas analysis、procalcitonin within 24 hours.The data of infection site、age、sex、vital signs were recorded.All the children had cerebrospinal fluid examination and only two cases with multiple organ dysfunction and using ventilator did not carry out cerebrospinal fluid examination.All the cases need to do the corresponding imaging examination to rule out diseases such as encephalitis,intracranial placeholder and bleeding.3 On the first day,the tenth day,and the twenty-eight day of the PICU admission,EEG monitoring for both the two groups of children was accomplished.If the EEG record is abnormal on the twenty-eight days,the patients need to see the doctor for follow-up care until six months out of hospital.4 We do the analysis by SPSS 18.0,Express by standard deviation(?x±s).Comparison between groups with T test,P<0.05 is supposed to difference was statistically significant.Result:1 Of all the 112 children with sepsis,there are thirty-four cases with SAE,and 10 deaths of patients.The morbidity of SAE in sepsis is 30.4%,and the mortality rate is 29.4%.The mean age of onset in SAE groop is(1.42±1.2)years;The mean age of onset in Non-SAE groop is(3.43±3.2)years;the difference was statistically significant.(P=0.002).2 PCIS and GCS Score of the SAE group are all lower than the Non-SAE group,he former is 66-79 score,the latter is 78-83 score,the difference was statistically significant(P=0.03);GCS score of the former is 6-12,the latter is13-15,the difference was statistically significant(P=0.01).3 Mechanical ventilation time of SAE group is longer than Non-SAE group,the former is7.8±5.6 days,the latter is 3.9±3.2days,the difference was statistically significant(P=0.003).4 The time of admission PICU: SAE group is longer than Non-SAE group.The former is 10.2±8.7days,the latter is 8.5±3.2days,the difference was statistically significant(P=0.002).5 The index of pulse,LAC,PCT and CRP in SAE group is higher than in Non-SAE group,while serum albumin and PH value is lower than Non-SAE group,the difference was statistically significant(P<0.05).The other indicators have no obvious difference(P>0.05).6 The positive rate of blood culture in SAE group and Non-SAE group: SAE group is 64.7%(22/34),Non-SAE group is 47.4%(37/78),the difference was statistically significant(P=0.002).7 The proportion of escherichia coli,staphylococcus aureus infection in SAE group is higher than the Non-SAE group,the difference was statistically significant(P<0.05).Infection site have no statistically significant difference between two groups.8 The CSF pressure increased in SAE group,and is normal in Non-SAE group,the difference was statistically significant(P=0.002);While cytology and biochemistry test are normal,there are no statistically significant difference between two groups(P>0.05).9 Two cases with multiple organ dysfunction and mechanical ventilation cannot do MRI,and three cases refused to do MRI.The rest of twenty-nine cases all performed MRI.Only one case has brain white matter changes.The positive rate is 3.4%,In the Non-SAE group,MRI is normal,there are no statistically significant difference between two groups(P=0.065).10 In SAE group,there are twenty-nine cases have abnormal EEG,the positive rate is 85.3%.In the thirteen children with clinical manifestation of spirit,drowsiness,mild cognitive change,EEG show normal α rhythm slow down,δ wave increase the first day,ten cases recovered normal on the tenth day,and three cases light abnormality,this three cases return to normal on the twenty-eighth day;The other sixteen cases Clinical manifestations of coma,convulsions who combine with SAE,their EEG show severe abnormality.There are fourteen cases EEG show diffuse θ with high amplitude slow wave,α rhythm slow down,inhibition of sharp spines、periodic wave、wave discharge,8 cases died.The survival six cases review EEG were still α rhythm slow dow,δ wave increase on the tenth day,even have triphasic-like waves.When they review EEG on the twenty-eighth day there are four cases return to normal,There are still two cases of abnormal :one showed α rhythm slow dow,δ wave increase,when we followed up to the sixtieth day it returned to normal.The other case have frequent seizures when hospitalization,and his EEG show more quantity sharp spike wave.spike-wave.Seizure controlled after treatment for 3 months.In the follow-up of half a year,the EEG of a child combined with hypophrenia still showed α rhythm slow down、sharp spike wave distribution.Two cases have no brain electrical activity died.But Non-SAE group all showed normal EEG.Conclusions:1 SAE is the severe and common complications of sepsis,with high mortality.The younger patients have the higher morbidity.Therefore,early correct diagnosis of SAE and carries on the positive intervention is important.2 There are negative correlation between the morbidity of SAE and GCS and PCIS score.the higher score have lower the morbidity of SAE.The duration of mechanical ventilation in SAE group is longer than the Non-SAE groop.3 The occurrence of SAE is associated with the severity of sepsis.In SAE group,PCT、CRP、pulse、LAC are higher than the Non-SAE group,the difference was statistically significant.The positive rate of blood culture in SAE group is higher,and the major pathogenic bacteria are staphylococcus aureus and escherichia coli.G+ bacterium and G-bacterium infection are more frequently in SAE than fungal infection.4 The CSF pressure is increased in SAE group,and is normol in Non-SAE group.The cytology and biochemistry test have no statistically significant difference between two groups.The positive rate of imaging examination is lower in SAE,and there is no significance in diagnose of SAE.5 The positive rate Electroencephalogram is higher in SAE group.The patients with deeper coma have the more serious EEG,and longer abnormal EEG.So EEG can be used as a sensitive indicators in prognosis assessment of SAE.