CAJ | 학술논문

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/m2）：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。
목적：분석위중형수족구병환인적림상특점，관찰위중형수족구병합병급성폐수종환인혈류동역학적동태변화。방법채용전첨성관찰성연구방법，선택2008년5월지2014년9월불산시제일인민의원중증가강치료병방（ICU）화인과수치적35례위중형수족구병합병급성폐수종환인，관찰기림상특점；병대기중5례진행맥박지시련속심배혈량（PiCCO）감측，관찰입ICU시（0 h）급치료24、48、96 h PiCCO삼수적동태변화。결과35례부합진단표준병존재림상폐수종표현적환인중남성22례，녀성13례；년령7개월～4세，기중≤1세6례，1～2세13례，2～3세12례，3～4세4례。기병후3～4 d시출현폐수종적주요시간；림상상균존재발열급중추신경계통증상，뇌척액검사결과균표현위무균성염성개변。PiCCO감측현시，치료후환인심솔（HR）、외주순배조력지수（SVRI）화혈관외폐수지수（EVLWI）균정축점하강추세，96 h시균명현저우0 h〔HR（차/min）：119.0±14.7비200.8±19.7，SVRI（kPa·s·L-1·m-2）：148.9±14.6비209.6±58.7，EVLWI（mL/kg）：10.5±1.9비34.8±10.8，P＜0.05혹P＜0.01〕，이전심서장기말용적지수（GEDVI）야축점하강，단각시간점간무통계학차이；매박량지수（SI）화심배혈지수（CI）균정승고추세，96 h명현고우0 h〔SI（mL/m2）：38.5±6.5비17.4±2.8， CI（mL·s-1·m-2）：75.0±8.0비55.5±8.5，균P＜0.01〕。대2례환인행초성심동도검사，제시좌심증대、좌실수축공능감퇴。소유환인중사망4례，1례유류지체공능장애，기여환인전유출원。결론위중형수족구병합병급성폐수종환인병정흉험、병사솔고；차류환인중추신경계통손해급좌실수축공능감퇴교위상견；결합PiCCO감측결과가이제시신경원성폐수종여심원성폐수종가능동시존재。
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/m2): 38.5±6.5 vs. 17.4±2.8, CI (mL·s-1·m-2): 75.0±8.0 vs. 55.5±8.5, bothP< 0.01]. Left atrium was found to be enlarged, and left ventricular systolic function decreased in two patients by cardiac ultrasonic. Four out of 35 patients died, and functional disability of extremities was found in 1 patient. Other patients were cured and discharged without any sequelae.Conclusions Severe HFMD complicated by acute pulmonary edema is a perilous condition in children, accompanied commonly by pathologic changes in central nervous system and systolic dysfunction of left ventricle. According to the results with PiCCO monitoring, HFMD patients suffering from acute pulmonary edema may be of cardiac origin in addition to neurogenic origin.