《【医学ppt课件】儿童重症肠病毒感染救治》由会员分享,可在线阅读,更多相关《【医学ppt课件】儿童重症肠病毒感染救治(74页珍藏版)》请在金锄头文库上搜索。
1、以病程分期為依據之兒童腸病毒重症治療 The Stage Based Therapy of Critically Ill Children with EV 71 Infection,林口長庚兒童醫院兒童加護科 夏紹軒 吳昌騰 兒童心臟科 黃茂盛 鍾宏濤 兒童神經科 林光麟 王傳育 兒童呼吸胸腔科 黃健燊 兒童感染科 張鑾英 黃玉成 邱政洵 林奏延,A Cardiopulmonary disaster requiring multidisciplinary treatment,I. Outbreaks II. 臨床分期及其表現 III. 呼吸衰竭的病生理學 IV. 治療的考量 V. 結論,Out
2、breaks (1),民國八十七年五月初一個一歲兩個月大的小女孩被帶到門診,主訴是 fever with oral ulcers and vesicles on hands, feet and knees. 母親對於小朋友的高燒不退、躁動不安、食慾減退、入睡困難、無力站立非常擔心。,Outbreaks (2),醫生說:這是典型手足口病症狀,只要吃一些退燒藥,多休息、多喝水就好了。 第二天,小女孩被帶回急診,已經發生意識不清、發紺等症狀,當時,急診醫師為她插上氣管內管,大量粉紅色泡沫狀液體從氣管內冒出。,Outbreaks (3),小女孩被送到 PICU. 發生心肺衰竭,CPR無效後,被宣布死亡
3、。 此後一個月,共有七名兒童因同一症狀死在本院,醫師立即通報疾病管制局,並發現幾乎全台灣各大醫學中心都有類似案例。,Enetrovirus type 71 腸病毒七十一型分別在糞便、咽喉、及腦脊髓液檢體中被培養出來。,EV 71 Outbreaks,Enterovirus type 71 was firstly isolated from the stool of an infant with encephalitis in US in 1969 1975, 44/705 were killed in Bulgaria 1997, 30 were killed in Malaysia 1998
4、, 78 were killed in Taiwan 1999, 8 were killed in Hong-Kong,1998 腸病毒流行之統計,估計約一百萬至兩百萬人口被感染?! 查有實據者129106人為EV71感染 405人為重症 78人死亡 80%死於肺水腫與肺出血,腸病毒的傳染途徑,飛沫傳染 唾液與呼吸道分泌物在痊癒之後2-3 weeks仍可分離出EV71病毒 糞口傳染 糞便在痊癒之後6-8 weeks仍可分離出EV71病毒 病毒離開人體可存活8小時左右,I. Outbreaks II. 臨床分期及其表現 III. 呼吸衰竭的病生理學 IV. 治療的考量 V. 結論,EV71(17
5、4) non71 EV(241),Uncomlicated cases HFMD/herpangina Viral exanthem Febrile illness Others Comlicated cases Meningitis Encephalitis/myelitis Polio-like syndrome Pulmonary Oedema Fatal cases Survivors with severe neurological sequela,119(68%) 108(63%) 2(1.1%) 7(4%) 2(1.1%) 55(32%) 13(7.5%) 26(14.5%)#
6、4(2.3%) 12(6.9%)# 14(8.0%)# 5(2.8%)#,187(78%) 105(43%) 5(2%) 18(7.4%) 59(24%) 54(22%) 44(18%) 5(2.1%) 0(0%) 0(0%) 0(0%) 0(0%),#:p150 9(82%) 4(11%) 38(6-211) 0.001 * Leukocytosis 9(82%) 12(32%) 9.7(2.9-34) 0.003 # Upper limb 4(36%) 4(11%) 4.9(2.6-9.2) 0.04 weakness Lower limb 7(64%) 11(29%) 4.3(2.0-9
7、.2) 0.04 weakness,Chang et al. Lancet 354(9191): 1682, 1999,Skin and Mucosa Lesions,Oral ulcers distributed not on soft palate only as typical hand-foot mouth disease Vesicles on hand and foot were smaller (pin-point) than typical HFM disease Sometimes the skin lesion consisted of petechiae-like clu
8、sters,Phases Based Therapy of Critical EV-71 Infection 腸病毒重症之臨床分期,第一期:上呼吸道感染手足口病 第二期:神經症狀腦膜腦脊髓炎 第三A期:高血壓肺水腫出血自主神經失調 第三B期:低血壓心臟衰竭?心肌炎?SIRS? 第四期:逐漸恢復神經後遺症,分期標的,Stage 1: Oral ulcer, skin rash, fever Stage 2: Neurological symptomsmyoclonic jerk, limb weakness, seizure, consciousness disturbance Stage 3A
9、: Elevated BP Stage 3B: Decreased BP, use of catecholamines Stage 4: Cessation of catecholamines.,Results,We observed a majority of patients (58% 14/24) presented different five clinical phases. Two patients developed PE without a HFM prodrome One patient developed PE without previous CNS involvemen
10、t signs In six patients, hypertension phases were not observed Three patients did not develop hypotension phenomenon,Table A Severe Hypertension Criteria by Age,Modified from Hycan et al Task Force on Blood Pressure control in Children. Pediatrics 79:1, 1987.,Table B. Normal Blood Pressure by Age,Ha
11、zinski MF: Nursing Care of the Critically Ill Child, 2nd ed. St.Louis, Mo: Mosby Year Book; 1992,第一期:手足口病,持續約數天 可能發高燒 類手足口病Hand-Foot-Mouth disease 類皰疹性咽峽炎Herpangina 大多數病人可自然痊癒,無後遺症 手足水泡較典型手足口病小約針尖大小 高危險群可能向後期發展,重症病例之前趨症狀及危險因子 I,重症病例前趨症狀四肢反射性抖動 (myoclonic jerk)嘔吐嗜睡,中樞神經受侵犯之危險因子年齡小於三歲高燒超過39度燒超過3天嗜睡、抽筋
12、、頭痛嘔吐高血糖(150mg/dl),重症病例之前趨症狀及危險因子 II,重症病例中肺水腫之危險因子年齡小於三歲高血糖(150mg/dl)肢體無力 白血球升高 重症包含中樞神經受侵犯及肺水腫,第二期:腦膜腦炎,持續數天 包括睡眠易驚醒startling、手足抖動myoclonic jerk、肢體無力weakness 可能嘔吐、嗜睡 可能發生痙攣 腦脊髓液可能有發炎跡象亦可能無 到此仍可能自然痊癒,或許有後遺症,第三A期:高血壓肺水腫出血自主神經失調?,持續約數小時至一天左右,民國八十七年肺水腫出血為最主要死因 血壓上升為最早徵兆、高燒、心搏過快200/min以上、呼吸急促、出冷汗。 高血糖(2
13、00mg/dl) 肺水腫、肺泡出血、血氧含量降低 神經症狀持續惡化,昏迷指數降低、四肢更無力,Lungs are congested,Red blood cells are found in small airways and alveoli,Parameters Sequence Around PE,Parameters Sequence (2),第三B期:低血壓:心臟衰竭,持續約二至七天 心搏速率漸降但血壓可能更低 肺水腫出血漸好轉但仍需呼吸器,自呼能力差 血糖正常化 神經症狀之變化:垂直眼震顫、斜視、肢體無力、抽筋等,此期間腦灌流可能變差造成缺氧缺血性腦病變。,第四期:逐漸恢復,持續?月?年 心臟功能幾乎完全恢復 肺功能可能不好但足堪負擔換氣,然而病人自呼、吞嚥功能不好有嚴重影響,所以仍需呼吸器支持。 漸漸甦醒,神經可能有嚴重後遺症 可能發生反覆性肺炎。,I. Outbreaks II. 臨床分期及其表現 III. 呼吸衰竭的病生理學 IV. 治療的考量 V. 結論,Pathophysiology of Pulmonary Oedema,Starlings formula Flow=K(PcPis) (OncplOncis),Interstitium,Alveolus,Lymphatics,Pulmonary capillary,