重症单元初始收治2例危重型新型冠状病毒肺炎的病例分析及文献复习

Report of the first two critical cases of corona virus disease 2019 in critical care unit and literature analysis

目的总结新型冠状病毒肺炎(简称新冠肺炎)暴发早期患者的临床诊疗经验。方法回顾性分析武汉大学人民医院重症医学科2020年1月12日收治2例危重型新冠肺炎患者的临床资料。结果病例1为74岁女性,因间断咳嗽咳痰12 d、气喘2 d于2020年1月12日入住本院。外院胸部CT检查显示为双肺多发感染性病变,后续查咽拭子新型冠状病毒(2019-nCoV)核酸呈阳性,确诊为新冠肺炎。最高呼吸支持为无创呼吸机辅助呼吸,经治疗于1月28日康复出院。病例2为50岁男性,因发热1周,伴胸闷、呼吸困难3 d于2020年1月13日入院。外院肺部CT显示双肺多发感染性病变,后续查咽拭子2019-nCoV核酸呈阳性,确诊为新冠肺炎。治疗过程中给予有创呼吸治疗6 d,经治疗于1月28日成功拔除气管插管,2月12日过渡至吸入氧浓度(FiO2)为0.30。本组2例患者发病过程均有发热症状,伴干咳,进而发展为呼吸困难及低氧血症;血常规检查显示患者均有淋巴细胞计数(LYM)下降,C-反应蛋白(CRP)升高,且随病情好转均伴有血中LYM回升;整个诊治过程中降钙素原(PCT)无明显升高,无证据表明合并细菌及真菌感染;血清乳酸脱氢酶(LDH)水平升高,反映肝肾功能的直接胆红素(DBil)及肌酐(Cr)水平正常,反映心功能的指标N末端脑钠肽前体(NT-proBNP)无明显波动。病例2细胞免疫CD4^+细胞计数、CD8^+细胞计数、CD16^+CD56^+细胞计数以及补体C3均随病情好转呈上升趋势。2例患者的主要治疗方案均为抗病毒、糖皮质激素、呼吸支持、丙种球蛋白提高免疫、营养支持、维持内环境稳定及肺康复锻炼等。病例1于1月28日康复出院;病例2病情好转。结论危重型新冠肺炎患者治疗难度大、周期长,需及时更改合适的呼吸支持手段,避免多器官功能衰竭发生,并完善各种治疗方案。

Objective To summerize the clinical experiences of patients with corona virus disease 2019(COVID-19)in early period of outbreak.Methods The clinical data of two criticle patients with COVID-19 in Intensive Care Unit of Renmin Hospital of Wuhan University on January 12,2020 were retrospectively analyzed.Results Case 1 was 74-year-old female hospitalized on January 12,2020.The chest CT images of other hospital showed multiple infectious lesions in both lungs,then the pharynx swab 2019 novel coronavirus(2019-nCoV)nucleic acid was positive and the patient was diagnosed as COVID-19.The highest respiratory support was non-invasive ventilation.The first patient recovered and was discharged on January 18 after treatment.Case 2,a 50-year-old male,was admitted to hospital on January 13,2020 due to fever for one week,chest distress and dyspnea for 3 days.The chest CT images of other hospital also showed multiple infectious lesions in both lungs,then the pharynx swab 2019-nCoV nucleic acid was positive,and the patient was diagnosed with COVID-19.The second patient accepted endotracheal intubation and invasive ventilation for 6 days and the tube was removed successfully on January 28.The fraction of inspired oxygen(FiO2)decreased to 0.30 on February 12.The two patients had fever symptoms during the course of onset,with dry cough,which developed into dyspnea and hypoxemia;blood routine showed that lymphocyte count(LYM)decreased,C-reactive protein(CRP)increased,and LYM increased with condition improved;procalcitonin(PCT)did not increase significantly in the whole process of diagnosis and treatment,and there was no evidence of bacterial and fungal infections;lactate dehydrogenase(LDH)in serum increased,the levels of direct bilirubin(DBil)and creatinine(Cr)reflecting liver and kidney function were normal,but N-terminal pro-brain natriuretic peptide(NT-proBNP)reflecting heart function had no obvious fluctuation.The number of CD4^+,CD8^+,CD16^+CD56^+and C3 in case 2 increased with the improvement of the disease.The main treatment measures included antiviral,glucocorticoid,respiratory support therapy,gamma globulin to improve immunity,nutrition support,stablilizing internal environment,lung rehabilitation exercise,etc.Case 1 was discharged from hospital on January 28;case 2 was improved Conclusions Patients with critical COVID-19 are difficult to treat and need long treatment cycle.We should select the appropriate kinds of respiratory support in time to avoid the occurrence of multiple organ failure,and improve various treatment programs.