体外膜肺氧合治疗恙虫病并多器官功能衰竭1例

A case of tsutsugamushi disease complicated by multiple organ dysfunction syndrome treated by extracorporeal membrane oxygenation

恙虫病是立克次体引起的急性传染病,在中国澳门偶有感染个案报道,危重症的个案更是罕见。由于恙虫病患者的临床症状呈非特异性及多样性,若不能及时诊治,病情可进展致多器官功能障碍综合征(MODS),出现严重的急性呼吸窘迫综合征(ARDS),甚至死亡。中国澳门镜湖医院重症监护病房(ICU)2021年9月30日收治1例恙虫病伴MODS患者,结合患者郊外活动史(接触恙虫幼虫)、临床症状、体征(腹部皮肤发现恙虫病特有焦痂)及实验室相关检查(外裴氏试验阴性),诊断为恙虫病伴MODS。入院后给予抗感染、纠正凝血功能障碍、气管插管机械通气、去甲肾上腺素维持血压、连续性肾脏替代治疗(CRRT)无明显改善。启动静脉-静脉体外膜肺氧合(VV-ECMO)支持。VV-ECMO初始设定血流量5 L/min(70 mL·kg^(-1)·min^(-1)),转速3500 r/min,吸入氧浓度(FiO_(2))1.00,肝素抗凝,监测活化凝血时间(ACT)180~200 s,同时调整CRRT脱水量;ECMO支持9 h后氧合改善,ECMO血流量下调至4 L/min(58 mL·kg^(-1)·min^(-1))左右,转速3000 r/min;ECMO治疗4 d患者病情好转,逐渐下调ECMO流量及FiO_(2);于入院5 d撤离ECMO支持。持续呼吸机支持8 d后,患者成功脱机并拔除气管插管;入院11 d停止CRRT改为间断血液透析治疗;入院12 d患者病情稳定转出ICU。之后患者自主尿量逐渐增加,各器官功能恢复正常,住院36 d后康复出院。

Tsutsugamushi disease is an acute infectious disease caused by Rickettsia.Occasionally it has been reported in Macao,China.Critical cases are rare.Because the clinical manifestations of tsutsugamushi disease are non-specific and diverse,if not diagnosed and treated in time,the disease may progress to multiple organ dysfunction syndrome(MODS),severe acute respiratory distress syndrome(ARDS),and even death.A patient with tsutsugamushi disease complicated by MODS was admitted to the intensive care unit(ICU)of Kiang Wu Hospital in Macao,China on September 30,2021.Combined with the history of outdoor activities(exposure to chigger mite larvae),clinical symptoms and signs(characteristic eschar of tsutsugamushi disease was found on the abdominal skin),related laboratory examinations(Weil-Felix test:negative).Diagnosis of tsutsugamushi disease with MODS.After admission,the patient was treated by anti-infection,correction of coagulation dysfunction,tracheal intubation and mechanical ventilation,noradrenalin to maintain blood pressure,continuous renal replacement therapy(CRRT),but the condition didn't improve significantly.We initiated veno-venous ECMO(VV-ECMO),which was initially setted blood flow to 5 L/min(70 mL·kg^(-1)·min^(-1)),rotate speed to 3500 rpm,fractional concentration of inspired oxygen(FiO_(2))to 1.00.Heparin was used as anticoagulant and activated coagulation time(ACT)was kept between 180 and 200 seconds.Meanwhile the speed of fluid removal in CRRT was adjusted.After 9 hours of ECMO support,the oxygenation improved,the blood flow of ECMO was reduced to about 4 L/min(58 mL·kg^(-1)·min^(-1)),rotate speed to 3000 rpm.The patient's condition improved after 4 days of ECMO treatment and her ECMO flow rate and FiO_(2) could be decreased gradually.On hospital day 5,ECMO was removed.Eight days on mechanical ventilation,the patient was successfully weaned and extubated.On day 11 of hospitalization,weaned the CRRT and turned to intermittent hemodialysis.The patient was transferred out of ICU due to her stable condition on the 12th day hospitalization.After that,her spontaneous urine output increased gradually.The functions of various organs returned to normal.After 36 days of hospitalization,she recovered and was discharged.