CAJ | 학술논문

目的：观察手足口病危重症患儿凝血系统状态与肺出血的关系，探讨临床凝血指标的早期诊断意义。方法采用前瞻性病例设计方法，选择2010年7月至2012年7月河北省儿童医院重症医学科收治的手足口病重型病例89例，按其严重程度分为重症组（46例）及危重症组（43例），将危重症组再按预后分为生存组26例和死亡组17例；健康对照组为同期44例同龄健康儿童。患儿入院后立即取血，进行血常规、凝血酶原时间（PT）、凝血酶时间（TT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（Fg）及D-二聚体检测。结果重症组、危重症组和健康对照组PT、TT、APTT及Fg水平差异均无统计学意义（均P＞0.05），重症组和危重症组血小板计数（PLT）明显低于健康对照组（×109/L：245±130、237±156比389±120），D-二聚体明显高于健康对照组（mg/L：0.34±0.67、0.41±0.08比0.24±0.13），且危重症组D-二聚体高于重症组（均P＜0.05）。危重症组病死率为39.5%，存活组和死亡组PT、APTT、Fg、TT及PLT比较差异均无统计学意义（均P＞0.05），而死亡组D-二聚体水平明显低于存活组（mg/L：0.60±0.09比0.12±0.09，P＜0.05）。结论重症及危重症手足口病凝血因子及血小板处于启动动员状态、轻度消耗状态，并存在纤溶抑制状态，尚未出现全身出血倾向，即处于弥散性血管内凝血（DIC）代偿期，不是肺出血的发生机制；监测D-二聚体对病情评估有临床意义。
목적：관찰수족구병위중증환인응혈계통상태여폐출혈적관계，탐토림상응혈지표적조기진단의의。방법채용전첨성병례설계방법，선택2010년7월지2012년7월하북성인동의원중증의학과수치적수족구병중형병례89례，안기엄중정도분위중증조（46례）급위중증조（43례），장위중증조재안예후분위생존조26례화사망조17례；건강대조조위동기44례동령건강인동。환인입원후립즉취혈，진행혈상규、응혈매원시간（PT）、응혈매시간（TT）、활화부분응혈활매시간（APTT）、섬유단백원（Fg）급D-이취체검측。결과중증조、위중증조화건강대조조PT、TT、APTT급Fg수평차이균무통계학의의（균P＞0.05），중증조화위중증조혈소판계수（PLT）명현저우건강대조조（×109/L：245±130、237±156비389±120），D-이취체명현고우건강대조조（mg/L：0.34±0.67、0.41±0.08비0.24±0.13），차위중증조D-이취체고우중증조（균P＜0.05）。위중증조병사솔위39.5%，존활조화사망조PT、APTT、Fg、TT급PLT비교차이균무통계학의의（균P＞0.05），이사망조D-이취체수평명현저우존활조（mg/L：0.60±0.09비0.12±0.09，P＜0.05）。결론중증급위중증수족구병응혈인자급혈소판처우계동동원상태、경도소모상태，병존재섬용억제상태，상미출현전신출혈경향，즉처우미산성혈관내응혈（DIC）대상기，불시폐출혈적발생궤제；감측D-이취체대병정평고유림상의의。
Objective To investigate the relationship between the coagulation system status and the pulmonary hemorrhage in children with severe hand,foot and mouth disease(HFMD)and approach the clinical significance of early detection of coagulation function. Methods By prospective case design method,89 cases with HFMD admitted to Department of Critical Care Medicine of Hebei Provincial Children Hospital from July 2010 to July 2012 were enrolled. The children were divided into severe group(46 cases)and critical group(43 cases)according to the severity of disease,and the children in critical group were subdivided into survivor group(26 cases)and non-survivor group (17 cases). Forty-four healthy children with the same age and in the same period were served as healthy control group. The blood of children was collected immediately after admission for determination of blood routine, prothrombin time(PT),thrombin time(TT),activated partial thrombin time(APTT),fibrinogen(Fg),and D-dimer (DD). Results There were no significant differences in PT,TT,APTT and Fg among severe group,critical group and health control group(all P>0.05). The blood platelets count(PLT)in severe group and critical group was significantly lower than that in health control group(×109/L:245±130,237±156 vs. 389±120),while the DD was significantly higher than that in healthy control group(mg/L:0.34±0.67,0.41±0.08 vs. 0.24±0.13),and the DD in critical group was obviously higher than that in severe group(all P<0.05). The mortality rate in critical group was 39.5%,and there were no significant differences in PT,APTT,Fg,TT and PLT between survivor group and non-survivor group(all P>0.05),but the DD in non-survivor group was significantly lower than that in survivor group(mg/L:0.60±0.09 vs. 0.12±0.09,P<0.05). Conclusions In children with severe or critical HFMD, the coagulation factor and blood platelet were in a state of mobilization,mild consumption state with the existence of fibrinolytic inhibition,but without systemic bleeding tendency,therefore it is in a compensatory stage of disseminated intravascular coagulation(DIC),not the mechanism of pulmonary hemorrhage. The monitor of DD has its clinical significance in evaluations of the disease situation and its prognosis.