Effects Of Glucocorticoid And Continuous Blood Purification On Prognosis And Cellular Immune Function In Children With Septic Shock

Sepsis refers to systemic inflammatory response syndrome(SIRS)caused by infection.Progressive disease can lead to multiple organ dysfunction syndrome(MODS)or multiple organ failure(MOF),which is an unit important cause of death in hospitalized children in pediatric intensive care(PICU).The etiology of sepsis is not fully understood,but with the continuous deepening of research,there is an increasing view that its pathogenesis is attributed to the imbalance of inflammatory response caused by infection,so that the tissues and organs suffer from severe inflammatory damage during this occurrence and development,eventually leading to organ damage and even functional failure.There has been controversy regarding the methods,types,timing of glucocorticoid use in children with septic shock and its effect on cellular immune function.Continuous blood purification therapy as a new treatment of sepsis in the last decade,there are also different conclusions on its mechanism of action,efficacy and the impact of cellular immunity.Therefore,this topic is divided into two parts to explore the different strategies of the use of glucocorticoids in children with septic shock in terms of cellular immune function and prognosis,and to explore its possible mechanisms of analysis,in order to better apply in the treatment of severe clinical children.Part Ⅰ:Effects of different glucocorticoids on prognosis and cellular immune function in children with septic shockObjectiveTo compare the effect of early low-dose glucocorticoids on prognosis and cellular immune function in children with septic shock.MethodsA cohort study was performed.Some children with septic shock admitted to our PICU between September 2013 and December 2018 were divided into control group,methylprednisolone group and dexamethasone group according to different treatment methods.Record and compare the pediatric critical illness score(PCIS)immediately after admission and 24h and 72h after treatment in each group;check blood routine,liver and kidney function,electrolytes,blood biochemistry,T cell subsets(CD3+,CD3+CD4+,CD3+CD8+),NK cells(CD16+56+),HLA-DR/CD14 and TNF-a,IL-10 levels;record and compare the duration of PICU stay and mortality at 3d,7d and 28d after treatment in each group.Results(1)There was no significant difference among the three groups in the mortality rate and the average duration of ICU stay at 3 days,7 days and 28 days.(2)After treatment,the PICS of each group of children increased,and there was no significant difference in the increase and speed among the three groups;(3)After treatment,the CD3,CD4+ T,CD4+/CD8+and CD16+56+ tended to normalize in each group,and there was no significant difference in the change speed and amplitude of the above indicators among the groups;(4)After treatment,the levels of TNF-α and IL-10 in the peripheral blood of each group of children were significantly lower than those before treatment at 72 hours after treatment.There was no significant difference in the change range and speed of TNF-α between the three groups;the decrease range and speed of IL-10 in the.methylprednisolone group and dexamethasone group were higher than those in the control group(P<0.05),but there was no significant difference in the decrease range and speed of IL-10 between the methylprednisone group and dexamethasone group;(5)After treatment,the expression level of HLA-DR in each group was increased,and there was no significant difference in the increase range and speed between methylprednisolone group and dexamethasone group,which was higher than that in the control group(P<0.05).Conclusion1.For catecholamine resistant shock,there was no significant difference in mortality between the two groups with early low-dose methylprednisolone or dexamethasone.2.Early low-dose methylprednisolone or dexamethasone can quickly restore the expression of HLA-DR and partially improve the cellular immune function in children with septic shock;3.There was no significant difference in the recovery of cellular immune function between methylprednisolone group and dexamethasone group.Part Ⅱ:Effects of Methylprednisolone and Continuous Blood Purification on Prognosis and Cellular Immune Function in Children with Septic ShockObjectiveTo compare the effect of early low-dose methylprednisolone and methylprednisolone combined with continuous blood purification on prognosis and cellular immune function in children with septic shock.MethodsA cohort study was performed and some children with septic shock admitted to our PICU between September 2013 and December 2018 were divided into control group,methylprednisolone group and hormone + blood purification group according to different treatment methods.The critical illness score(PCIS),blood routine,liver and kidney function,electrolytes,blood biochemistry,T cell subsets(CD3+,CD3+CD4+,CD3+CD8+),NK cell(CD16+56+),HLA-DR/CD14,TNF-α and IL-10 levels were compared between the groups immediately after admission and 24 h and 72 h after treatment.The duration of PICU stay and mortality at 3 days,7 days and 28 days after treatment were recorded and compared between the groups.Results(1)There was no significant difference in the average number of days of PICU stay between the three groups;in the hormone + blood purification group,the mortality rate was the highest on the 3rd day of admission(P = 0.046),but there was no new death between the 3rd and 7th day of admission in this group,and only one new death occurred between the 7th and 28th day of admission,which was less than the number of new deaths in the control group and methylprednisolone group in the same time period;(2)Before treatment,PCIS of hormone + blood purification group was the lowest;24 h and 72 h after treatment,PCIS of all groups increased compared with that before treatment,and the clinical symptoms were improved;hormone + blood purification group had the most significant increase rate and amplitude of PCIS;(3)Before treatment,the CD3+,CD3+CD4+,CD4+/CD8+ and CD 16+56+ were lower in the three groups;after treatment,the CD4+,CD4+/CD8+,and CD16+56+ were the highest;(4)Before treatment,the average levels of TNF-a and IL-10 in the three groups were significantly increased and gradually decreased after treatment.Among them,the hormone + blood purification group showed the most significant changes in speed and magnitude(P<0.05);(5)Before treatment,the HLA-DR/CD14 expression level of all groups of children decreased,with the lowest expression level in the blood purification group;after treatment,the HLA-DR expression level of all groups of children increased,and the hormone + blood purification group had the most significant increase speed and amplitude(P<0.05).Conclusion1.Compared with methylprednisolone group,hormone + blood purification group had the most serious disease,so the 3-day mortality was the highest,but there was no significant difference in 7-day/28-day mortality.2.Compared with methylprednisolone group,clinical symptoms and cellular immune function recovered more quickly in methylprednisolone + blood purification group.