| Background and PurposePneumonia was the most common respiratory infection in children, and children with severe pneumonia were often associated with gastrointestinal dysfunction, resulted in intestinal endotoxin absorption and bacterial translocation which made the illness worse, so it was an important part of the occurrence and development of multiple organ damage and failure caused by pneumonia. Currently the diagnosis of gastrointestinal dysfunction was still lack of unified standard, when there had the performance such as a high clinical abdominal distension, bowel sounds decreased or disappeared, gastrointestinal bleeding and other symptoms prompt the disease was already in advanced tips, losted the best rescue time. The European Society of Intensive Care Medicine(ESICM) issued on the classification standard of acute gastrointestinal injury(AGI) in 2012, according to the clinical manifestations of gastrointestinal dysfunction and the impact on the overall patient, AGI could be divided into four, the higher the level prompted the more severe symptoms of gastrointestinal dysfunction, but the clinical doctor’s subjective factors had greater influence on the classification method, so looking for objective biological markers were important for the early diagnosis of gastrointestinal dysfunction. Intestinal fatty acid binding protein(IFABP) was a low molecular weight protein substance that only existed at the top of the microvilli in the mature small intestinal mucosa, when the body was subjected to various trauma that causeed gastrointestinal mucosa occured hypoxia and ischemia, intestinal barrier function was impaired, intestinal epithelial cells losed the normal polarity, the cell surface skeleton rearrangemented, the integrity of the intestinal epithelial cell membrane was damaged, the permeability of intestinal mucosa increased, its intestinal fatty acid binding protein could enter the blood circulation through the damaged intestinal mucosa, so it could be used as a sensitive indicator to evaluate the early intestinal ischemia. D-lactic acid(D-LAC) was a unique product that was produced by intestinal bacteria, because D-lactic acid was only produced in the gastrointestinal tract of human body, and the human,s body could not removed the enzyme quickly, so D-lactic acid almost entirely produced from gastrointestinal tissues. Under normal circumstances, because of the intestinal mucosal barrier filter macromolecules, D-lactic acid could hardly enter the blood circulation, once the intestinal damaged, the damaged intestinal barrier function could not continue to prevent the macromolecules into the blood circulation, so D-lactic acid could be released into the blood through increased permeability of intestinal mucosa, therefore serum D-lactic acid levels could also be used to assess the severity of intestinal mucosal barrier dysfunction. At home and abroad had been reported that serum intestinal fatty acid binding protein and D-lactic acid were closely related to the gastrointestinal dysfunction and prognosis of multiple injuries, severe pneumonia, severe pancreatitis, sepsis and others in adults, but the studies of pneumonia in children were rare, and in view of intestinal fatty acid binding protein with high sensitivity, the specificity of D-lactic acid was strong, therefore, this study was through the determination of serum intestinal fatty acid binding protein and D-lactic acid on days 0 and 3 after admission in children with pneumonia, evaluated the severity of pneumonia in children by pediatric critical illness score(PCIS),assessed the gastrointestinal damage of children with pneumonia by AGI classification, and studied the correlation of them with serum intestinal fatty acid binding protein and D-lactic acid. To investigated the changes in serum intestinal fatty acid binding protein and D-lactic acid and their relationships with gastrointestinal dysfunction in children with pneumonia. Object and Methods1. A prospective observational study was conducted. Eighty two children with pneumonia admitted to pediatrics and pediatric intensive care unit of the First Affiliated Hospital of Zhengzhou University from January to October 2015 were enrolled, divided them into the mild pneumonia group and the severe pneumonia group according to the guidelines for the management of community-acquired pneumonia in children with the breathing the Subspecialty Group revised in 2013. The severe pneumonia group was divided into non-critical group and critical group according to the pediatric critical illness score. Exclusion criteria: children combined immune system diseases or immunosuppression(liked hematological system diseases, bone marrow depression after chemotherapy and so on); children combined other infections diseases, such as central nervous system infection, urinary system infection; children combined gastrointestinal disease; children used nearly a month of antibiotic, probiotics, hormones and other drugs; children received surgery or suffered severe trauma in seven days; children died or abandoned treatment in three days. And thirty healthy children served as control group.2. Collected the serum specimens when children admission and three days after admission, the control group also collected the serum specimens. Used the yellow SST Vacutainer by the USA BD company to collect 3ml peripheral blood specimens, and centrifuged for 10 minutes by 3000 rev/min to separate the serum, then placed in-80 ℃ refrigerator for inspection.3. Collected the general informations of the study objects, such as age, sex, clinical manifestation,diagnosis; graded the children with severe pneumonia of AGI grade,used the grading standards of acute gastrointestinal injury which released by ESICM in 2012.Recorded the pediatric critical illness score on days 0 and 3 after admission in children with pneumonia.4. Used the enzyme-linked immunosorbent assay kit provided by USA R & D Company for determining the content of serum IFABP on days 0 and 3 after admission in children with pneumonia.5. Used a modified enzyme-linked by UV spectrophotometry, determined the sample tubes absorbance(A) values at 340 nm by Beckman Du7 UV spectrophotometer, and computed the concentration of D-lactate acid according to standard tube absorbance(A) values on days 0 and 3 after admission in children with pneumonia.6. Correlation analysis with intestinal fatty acid binding protein, D- lactic acid, pediatric critical illness score and acute gastrointestinal injury classification in children with severe pneumonia.7. SPSS 21.0 statistical software was used for data analysis. Normally distribution of measurement data using mean ± standard deviation, t-test was used to compare the two groups, among the groups were compared by using one-way ANOVA analysis of variance; non-normal distribution of measurement data using median(inter-quartile range), indicates between the two groups were compared using rank sum test. Count data using the number of cases, between the two groups were compared using the chi-square test. Correlation analysis using Pearson correlation or Spearman rank correlation analysis. P<0.05 was considered statistically significant. Results1. Comparison of general information: 82 patients entered the final statistical analysis, in which mild pneumonia in 34 cases, 20 males and 14 females, with a median age of 3.00(2.44, 3.23) years; and severe pneumonia in 48 cases, 24 males and 24 females, with a median age of 3.00(2.51, 3.49) years.The AGI grade of children with severe pneumonia: 12 cases of grade 1, 14 cases of grade 2, 16 cases of grade 3, and 6 cases of grade 4. According to pediatric critical illness score in children with severe pneumonia, they were divided into two groups, one group was non-critical group, included 25 cases, among them had 13 males and 12 females, with a median age of 3.00(2.42, 3.58) years; another group was critical group, included 23 cases, among them had 11 males and 12 females, with the median age of 3.00(2.09, 3.21) years. Healthy control group of 30 cases, included 14 males and 16 females, with the average age of(3.26 ± 1.37) years. The groups in age, gender were no difference significant(all P>0.05).2. The content of serum intestinal fatty acid binding protein among the groups:(1) The content of serum intestinal fatty acid binding protein were all increased in children with mild pneumonia and severe pneumonia compared with those of control group(F=339.288, F=168.348, all P<0.001).(2)According to pediatric critical illness score, among children with severe pneumonia, the content of serum intestinal fatty acid binding protein in critical group on admission and three days after admission were higher than those of non-critical group(t=-0.600, t=-4.487, all P<0.01).(3) According to AGI grade of children with severe pneumonia, the content of serum intestinal fatty acid binding protein from 1 ~ 4 groups were all higher than those of the healthy control group( F=55.361, F=16.466, all P<0.01), and between different two groups were statistically significant(P <0.01).3. The concentration of serum D-lactic acid among the groups: The content of serum D-lactic acid were all increased in children with mild pneumonia and severe pneumonia compared with those of control group( F=221.910, F=115.075, all P<0.001).(2)According to pediatric critical illness score, among children with severe pneumonia, the content of serum D-lactic acid in critical group on admission and three days after admission were higher than those of non-critical group(t=-8.100, t=-5.284, all P<0.01).(3) According to AGI grade of children with severe pneumonia, the content of serum D-lactic acid from 1 ~ 4 groups were all higher than those of the healthy control group( F=64.165, F=13.036, all P<0.01), and between different two groups were statistically significant(P <0.01).4. Correlation analysis: The serum intestinal fatty acid binding protein and pediatric critical illness score of children with severe pneumonia on admission and three days after admission were negatively correlated(r=-0.950, r=-0.883, all P<0.01);the serum intestinal fatty acid binding protein and AGI grade in children with severe pneumonia on admission and three days after admission were positive correlated(r=0.901, r=0.735, all P<0.01).The serum D-lactic acid and pediatric critical illness score of children with severe pneumonia on admission and three days after admission were also negatively correlated(r=-0.0.868, r=-0.844, all P<0.01), and the serum D-lactic acid and AGI grade in children with severe pneumonia on admission and three days after admission were also positive correlated(r=0.916, r=-0.797, all P<0.01). Conclusion1. The heavier pneumonia cases, the more severe gastrointestinal dysfunction.2. Serum intestinal fatty acid binding protein and D-lactic acid can be used as sensitive and specific biochemical markers to evaluate the severity of disease and early detect the gastrointestinal damage in children with pneumonia. |
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