危重型手足口病合并急性肺水肿患儿的临床特点  

Clinical feature of severe hand, foot and mouth disease with acute pulmonary edema in pediatric patients

作　　者：周立新[1] 李轶男[1] 麦志广[1] 强新华[1] 汪首振[1] 誉铁鸥[1] 方滨[1] 温伟标[1] 

机构地区：[1]佛山市第一人民医院ICU,广东佛山528000

出　　处：《中华危重病急救医学》2015年第7期563-567,共5页Chinese Critical Care Medicine

基　　金：广东省科技计划项目（20118031800373）;广东省佛山市科技攻关项目（20111021010130）

摘　　要：目的：分析危重型手足口病患儿的临床特点，观察危重型手足口病合并急性肺水肿患儿血流动力学的动态变化。方法采用前瞻性观察性研究方法，选择2008年5月至2014年9月佛山市第一人民医院重症加强治疗病房（ICU）和儿科收治的35例危重型手足口病合并急性肺水肿患儿，观察其临床特点；并对其中5例进行脉搏指示连续心排血量（PiCCO）监测，观察入ICU时（0 h）及治疗24、48、96 h PiCCO参数的动态变化。结果35例符合诊断标准并存在临床肺水肿表现的患儿中男性22例，女性13例；年龄7个月～4岁，其中≤1岁6例，1～2岁13例，2～3岁12例，3～4岁4例。起病后3～4 d是出现肺水肿的主要时间；临床上均存在发热及中枢神经系统症状，脑脊液检查结果均表现为无菌性炎性改变。PiCCO监测显示，治疗后患儿心率（HR）、外周循环阻力指数（SVRI）和血管外肺水指数（EVLWI）均呈逐渐下降趋势，96 h时均明显低于0 h〔HR（次/min）：119.0±14.7比200.8±19.7，SVRI（kPa·s·L^-1·m^-2）：148.9±14.6比209.6±58.7，EVLWI（mL/kg）：10.5±1.9比34.8±10.8，P＜0.05或P＜0.01〕，而全心舒张期末容积指数（GEDVI）也逐渐下降，但各时间点间无统计学差异；每搏量指数（SI）和心排血指数（CI）均呈升高趋势，96 h明显高于0 h〔SI（mL/m^2）：38.5±6.5比17.4±2.8， CI（mL·s^-1·m^-2）：75.0±8.0比55.5±8.5，均P＜0.01〕。对2例患儿行超声心动图检查，提示左心增大、左室收缩功能减退。所有患儿中死亡4例，1例遗留肢体功能障碍，其余患儿痊愈出院。结论危重型手足口病合并急性肺水肿患儿病情凶险、病死率高；此类患儿中枢神经系统损害及左室收缩功能减退较为常见；结合PiCCO监测结果可以提示神经源性肺水肿与心源性肺水肿可能同时存在。ObjectiveTo explore the clinical feature of severe hand, foot and mouth disease （HFMD） in pediatric patients, and to observe the hemodynamic changes in those with acute pulmonary edema.Methods A prospective observation study was conducted. Thirty-five severe HFMD pediatric patients with acute pulmonary edema admitted to the intensive care unit （ICU） and Department of Pediatric of First People＇s Hospital of Foshan from May 2008 to September 2014 were enrolled. The clinical features were thoroughly investigated. Hemodynamic data were monitored by pulse-indicated continuous cardiac output （PiCCO） in 5 cases, and the changes in PiCCO parameters were observed at ICU admission （0 hour）, and 24, 48, 96 hours after treatment.Results Thirty-five patients who met the diagnostic standard of severe HFMD were enrolled, including 22 male and 13 female, aged from 7 months to 4 years. Six patients were younger than 1 year, 13 1-2 years, 12 2-3 years, and 4 patients 3-4 years old. The most common time of occurrence of pulmonary edema was 3-4 days after the onset of the disease. Fever and central nervous system symptoms were found in all the patients, and examination of the cerebral spinal fluid （CSF） revealed non-bacterial inflammatory changes. PiCCO results showed a tendency of lowering of heart rate （HR）, systemic vascular resistance index （SVRI）, and extravascular lung water index （EVLWI） after the treatment, and the values obtained at 96 hours were significantly lower than those at 0 hour [HR （bpm）： 119.0±14.7 vs. 200.8±19.7, SVRI （kPa·s·L^-1·m^-2）：148.9±14.6 vs. 209.6±58.7, EVLWI （mL/kg）： 10.5±1.9 vs. 34.8±10.8,P〈 0.05 orP〈 0.01], global end-diastolic volume index （GEDVI） was also gradually decreased without significant differences among all the time points, together with a tendency of increase in stroke volume index （SI） and cardiac index （CI）. The values of the parameters at 96 hours were significantly higher than those at 0 hour [SI （mL/m^2）�

关 键 词：手足口病 危重型 肺水肿 脉搏指示连续心排血量 

分 类 号：R720.597[医药卫生—急诊医学]