摘要目的:探讨脓毒症合并心肌损伤患儿的临床特征以及影响预后的相关因素。方法:回顾性分析2017年1月至2019年1月昆明市儿童医院重症监护病房的脓毒症合并心肌损伤患儿的临床资料。记录入院时小儿危重病例评分（PCIS）、性别、年龄、感染部位、临床转归、是否行机械通气和血液净化。记录病原学检测结果、肌酸激酶（CK）、肌酸激酶同工酶MB（CK-MB）、肌红蛋白、高敏心肌肌钙蛋白T（hs-cTnT）、降钙素原（PCT）、乳酸、左室射血分数（LVEF）、心输出量、左室短轴缩短率（LVFS）。将患儿按临床结果分为好转组和恶化组，比较各组的临床资料。采用受试者工作特征（ROC）曲线和多因素Logistic回归分析筛选可预测患儿预后的相关临床指标。结果:共入选脓毒症合并心肌损伤患儿138例，28 d死亡30例，28 d病死率为21.7%；呼吸道为主要感染部位，病原菌以革兰阴性菌和病毒为主，35.4%（28/79）患儿合并多系统感染。好转组102例；恶化组36例，院内死亡5例和自动出院31例。恶化组女性患儿比例明显高于好转组［63.9%（23/36）比34.3%（35/102）］，差异有统计学意义（ P<0.01）；两组年龄、感染部位、机械通气、血液净化及PCIS比较差异无统计学意义（ P>0.05）。恶化组hs-cTnT和乳酸明显高于好转组［（1.87 ± 0.67） ng/L比（1.62 ± 0.51） ng/L和（0.46 ± 0.31） ng/L比（0.34 ± 0.27） ng/L］，差异有统计学意义（ P<0.05）；两组CK、CK-MB、肌红蛋白、PCT、LVEF、心输出量和LVFS比较差异无统计学意义（ P>0.05）。ROC曲线分析结果显示，hs-cTnT和乳酸可预测脓毒症合并心肌损伤患儿的预后，曲线下面积为0.623和0.613，最佳截断值为159.59和2.65 ng/L，敏感度为36.1%和55.6%，特异度为98.2%和70.6%。多因素Logistic回归分析结果显示，影响患儿预后的独立危险因素为hs-cTnT和性别（ OR = 2.237和0.286，95% CI 1.093～4.578和0.127～0.644， P = 0.028和0.003）。 结论:儿童脓毒症合并心肌损伤患儿的28 d病死率较高，呼吸道为最常见的感染部位。hs-cTnT和乳酸水平升高在一定程度上提示脓毒症合并心肌损伤患儿的预后较差。hs-cTnT和性别是影响患儿预后的独立危险因素。

abstractsObjective:To investigate the clinical features and prognostic factors in children with sepsis complicated with myocardial injury.Methods:The clinical data of children with sepsis complicated with myocardial injury from January 2017 to January 2019 in Department of Intensive Care Unit, Children′s Hospital of Kunming City, were retrospectively analyzed. The pediatric critical illness score (PCIS) at admission, gender, age, infection site, clinical outcome, mechanical ventilation and blood purification were recorded. The etiological results, creatine kinase (CK), creatine kinase isoenzyme MB (CK-MB), myoglobin, hypersensitive cardiac troponin T (hs-cTnT), procalcitonin (PCT), lactate, left ventricular ejection fraction (LVEF), cardiac output, left ventricular truncation rate (LVFS) were recorded. According to the clinical results, the children were divided into improvement group and deterioration group, and the clinical data of each group were compared. The receiver operating characteristic (ROC) curve and multivariate Logistic regression were used to screen the relevant clinical indicators that could predict the prognosis of children.Results:A total of 138 children with sepsis complicated with myocardial injury were enrolled. Thirty cases died in 28 d, and the mortality of 28 d was 21.7%. The respiratory tract was the main infection site, and the main pathogens were gram-negative bacteria and virus. The 35.4% (28/79) of children were complicated with multiple infections. There were 102 cases in improvement group; and there were 36 cases in deterioration group, among whom 5 cases died in hospital and 31 cases was discharged without treatment. The proportion of the girls in deterioration group was significantly higher than that in improvement group: 63.9% (23/36) vs. 34.3% (35/102), and there was statistical difference ( P<0.01); there were no statistical differences in age, infection site, mechanical ventilation, blood purification and PCIS between 2 groups ( P>0.05). The hs-cTnT and lactate in deterioration group were significantly higher than those in improvement group: (1.87 ± 0.67) ng/L vs. (1.62 ± 0.51) ng/L and (0.46 ± 0.31) ng/L vs. (0.34 ± 0.27) ng/L, and there were statistical differences ( P<0.05); there were no statistical differences in CK, CK-MB, myoglobin, PCT, LVEF, cardiac output and LVFS between 2 groups ( P>0.05). ROC curve analysis result showed that the hs-cTnT and lactate were risk factors for predicting clinical prognosis in children with sepsis complicated with myocardial injury, the area under the curve were 0.623 and 0.613, the optimal value were 159.59 and 2.65 ng/L, with a sensitivity of 36.1% and 55.6%, and a specificity of 98.2% and 70.6%. Multivariate Logistic regression analysis result showed that the hs-cTnT and gender were independent risk factors for prognosis ( OR = 2.237 and 0.286, 95% CI 1.093 to 4.578 and 0.127 to 0.644, P = 0.028 and 0.003). Conclusions:The 28 d mortality in children with sepsis complicated with myocardial injury is higher, and the respiratory tract is the most common infection site. The increased hs-cTnT and lactate levels indicate that the prognosis is poor in children with sepsis complicated with myocardial injury. The hs-cTnT and and gender are independent risk factors of prognosis.