儿童重症手足口病并神经源性肺水肿死亡的危险因素

Risk Factors Associated with Death of Childhood Severe Hand-Foot-and-Mouth Disease with Neurogenic Pulmonary Edema

目的探讨儿童重症手足口病(HFMD)并神经源性肺水肿(NPE)的死亡危险因素,以利于指导疾病早期认识、诊断和治疗,从而降低病死率。方法收集2010年3-6月本院PICU收治的42例重症HFMD并神经源性肺水肿患儿资料,并根据患儿预后将42例患儿分为存活组(对照组)和死亡组(死亡或放弃治疗后死亡),比较2组患儿性别、年龄、小儿危重症评分(PCIS)、多脏器功能不全综合征(MODS)受累器官数、白细胞计数、中性粒细胞比值、血小板计数、上机时血糖、上机时心率、上机时血压、乳酸水平、碱剩余(BE)、CK、CK-MB、肌钙蛋白、降钙素原(PCT)、CRP、肺出血、意识障碍、惊跳、氧合指数、应激性溃疡、循环衰竭、发病病程等24个因素。采用单因素分析,筛选出P<0.05的相关危险因素进行多因素Logistic回归分析,分析可能的死亡危险因素。结果 42例中死亡16例,病死率38.1%。肺出血18例(其中死亡14例),死亡16例中均有发热、惊跳及循环衰竭,15例手足或手足臀部有针尖样散在皮疹,1例无皮疹。合并3个脏器功能障碍者8例(其中4例死亡),4个脏器功能障碍的11例全部死亡,5个脏器功能障碍1例死亡。单因素分析显示,PCIS、MODS受累器官数、白细胞计数、中性粒细胞比值、血小板计数、上机时血糖、上机时心率、乳酸水平、BE、CK-MB、肌钙蛋白、肺出血、意识障碍、氧合指数、应激性溃疡和循环衰竭16个因素与重症HFMD并神经源性肺水肿的死亡有关。将以上因素进行多因素Logistic回归分析,仍然与死亡有关的因素包括血清乳酸值、CK-MB和PCIS。结论重症HFMD并神经源性肺水肿病死率高,尤其是出现肺出血及循环衰竭时。PCIS降低、乳酸水平升高和CK-MB增高是该病死亡的危险因素。

Objective To evaluate the risk factors associated with the death of childhood severe hand-foot-and-mouth disease（HFMD） with neurogenic pulmonary edema（NPE）,which aims to be a guideline of early awareness,early diagnosis,treatment and reduce mortality. Methods Data of consecutive cases（n=42） which were confirmed severe HFMD with NPE admitted to Pediatric Intensive Care Unit（PICU） in Hunan Provincial Children′s Hospital from Mar.2010 to Jun.2010.According to the prognosis of diseases,42 cases were divided into survival group（controlled group） and death group（death and death after giving up）.The 24 variables included gender,age,pe-diatric critical illness score（PCIS）,the number of organs involved in multiple organ dysfunction syndrome（MODS）,white blood cell（WBC） count,neutrophilic granulocyte,platelet count,blood glucose when mechanical ventilation were given,heart rate when mechanical ventilation were given,blood pressure when mechanical ventilation were given,lactic acid,buffuer excess（BE）,creatine kinase（CK）,CK-MB,troponin,procalcitonin,C-reactive protein（CRP）,pulmonary hemorrhage,consciousness disorders,startle,oxygenation index,stress ulcer and circulatory failure,duration of disease were compared between 2 groups.The related risk factors which P value was lower than 0.05 were screened by single factor analysis and analyzed by multivariate Logistic regression analysis,and risk factors for death were analyzed. Results Sixteen cases were dead,and the mortality was 38.1%.Pulmonary hemorrhage were seen in 18 cases（14 cases were dead）.All 16 cases in the dead group had a fever,startle and circulatory failure,in which 15 cases had scattered needle-like rash on hand and foot or hand,foot and buttock,except 1 case.Eight cases had 3 organs involved in organ dysfunction and 4 cases of them were dead,11 cases had 4 organs and all of them were dead,1 case had 5 organs and dead finally.The single factor analysis showed that 16 variables included PCIS,the number of organs involved in MODS,WBC count,neutrophilic granulocyte,platelet count,blood glucose when mechanical ventilation were given,heart rate when mechanical ventilation were given,lactic acid,BE,CK-MB,troponin,pulmonary hemorrhage,consciousness disorders,oxygenation index,stress ulcer and circulatory failure were associated with the death of childhood severe HFMD with NPE,and the variables were analyzed by multivariate Logistic regression analysis.Lactic acid,CK-MB and PCIS were entered into the equation and were the factors associated with death. Conclusions The mortality in patients with severe HFMD with NPE are much higher,especially pulmonary hemorrhage and circulatory failure are existed.PCIS decreased,lactic acid and CK-MB increased are the risk factors associated with the death of childhood severe HFMD with NPE.