儿童暴发性心肌炎40例临床分析

发布时间：2018-04-22 14:20

本文选题：儿童 + 暴发性心肌炎　；参考：《浙江大学》2017年硕士论文

【摘要】：研究目的:通过总结儿童暴发性心肌炎的临床特点及治疗措施,为儿童暴发性心肌炎的早期诊断及治疗提供临床依据;并为进一步大样本随机对照研究打下基础。研究方法:回顾性分析浙江大学医学院附属儿童医院2009年03月至2016年12月临床诊断暴发性心肌炎并收治住院的40例患者的临床资料,根据是否接受体外膜肺氧合(Extracorporeal membrane oxygenation,ECMO)治疗,将患者分为未接受 ECMO治疗组(27例)和接受ECMO治疗组(13例),在两个治疗组中,根据患者预后,再将其分为死亡组和存活组,应用SPSS17.0统计软件分析,对患者的一般情况、临床表现、辅助检查结果、治疗方法及转归等方面进行归纳总结。结果:1、一般资料:40例FMC患儿,男性22例(55%),女性18例(45%),年龄2个月至13岁,平均发病年龄(7.50±3.85)岁;至我院就诊时间最短8小时,最长10天,中位就诊时间3天。2、临床表现及体征:首发症状以消化系统症状(72.5%)最常见,14例(35%)有前驱上呼吸道感染症状,20例(50%)患者有发热表现;临床体征以心音低钝(70%)及肝脏肿大(40%)最常见。3、辅助检查结果:(1)病原学检查:25例患者行柯萨奇病毒PCR检测,结果均为阴性。(2)白细胞计数与超敏C反应蛋白:42.5%(17/40)患者白细胞计数升高,中位白细胞计数10.70×10＾9/L,在未接受ECMO治疗组中,死亡组白细胞计数高于存活组,差异有统计学意义(P0.05);48.7%(19/39)患者超敏C反应蛋白升高,中位超敏C反应蛋白7mg/L。(3)CKMB质量、超敏肌钙蛋白T及N末端B型利钠肽原:分别有88.8%(32/36)和94.4%(34/36)的患者CKMB质量及超敏肌钙蛋白T升高,在接受ECMO治疗组中,死亡组超敏肌钙蛋白T高于存活组,差异有统计学意义(P0.05);所有患者N末端B型利钠肽均有不同程度升高,且在未接受ECMO治疗组中,死亡组N末端B型利钠肽高于存活组,差异有统计学意义(P0.05)。(4)心电图:97.3%患者心电图存在异常,主要表现为ST段改变(57.8%),窦性心动过速(52.6%)、各型房室传导阻滞(34.2%)及室性心动过速(34.2%)。(5)超声心动图:主要表现为左室射血分数降低(71.7%),心房或心室扩大(28.2%),室间隔及左室后壁增厚(20.5%)等;在未接受ECMO治疗组中,死亡组左室射血分数低于存活组,差异有统计学意义(P0.05)。4、治疗:分别有97.5%和87.5%的患者接受大剂量激素冲击和丙种球蛋白治疗,13例患者接受ECMO治疗;未接受ECMO治疗组的死亡率(48.1%)高于接受ECMO治疗组(15.4%),差异有统计学意义(P0.05)。5、转归:40例患者中,15例(37.5%)患者死亡,23例(57.5%)患者存活,2例患者出院后转康复治疗。结论:儿童暴发性心肌炎临床表现多样,首发症状多以心外表现多见,其中消化系统症状最常见,故早期诊断比较困难;目前柯萨奇病毒(PCR检测)检出率大大降低,而心肌标志物及N末端B型利钠肽仍是诊断暴发性心肌炎的重要标志;白细胞计数及N末端B型利钠肽的升高、左室射血分数的下降可能是影响儿童暴发性心肌炎预后的危险因素;暴发性心肌炎传统的治疗包括对症支持治疗、抗心衰、抗休克、抗心律失常、大剂量激素冲击及丙种球蛋白治疗,而ECMO的应用,大大提高了儿童暴发性心肌炎的抢救成功率,成为救治儿童暴发性心肌炎的可靠手段。
[Abstract]:Objective: to provide a clinical basis for early diagnosis and treatment of fulminant myocarditis in children by summarizing the clinical characteristics and treatment measures of fulminant myocarditis in children, and laying a foundation for further large sample randomized controlled study. Research methods: a retrospective analysis of the Affiliated Children's Hospital of Zhejiang University medical school from 03 months to December 2016 2009. Clinical data of 40 patients who were clinically diagnosed with fulminant myocarditis and admitted to hospital were divided into unaccepted ECMO treatment group (27 cases) and ECMO treatment group (13 cases) based on the treatment of Extracorporeal membrane oxygenation (ECMO). In two treatment groups, the patients were divided into death according to the prognosis. Group and survival group, using SPSS17.0 statistical software analysis to summarize the general situation, clinical manifestations, auxiliary examination results, treatment methods and outcomes. Results: 1, general data: 40 children with FMC, 22 men (55%), 18 women (45%), age 2 to 13 years old (7.50 + 3.85) years of age; to our hospital The shortest 8 hours, the longest 10 days, the median time of 3 days.2, clinical manifestations and signs: the first symptoms of digestive system symptoms (72.5%) are the most common, 14 cases (35%) have the symptoms of upper respiratory tract infection, 20 cases (50%) have fever performance; clinical signs with low blunt heart sound (70%) and liver swelling (40%) the most common.3, auxiliary examination results: (1) results: (1) pathogenic results Examination: 25 cases were detected by Coxsackie virus PCR, and the results were all negative. (2) white blood cell count and hypersensitivity C reaction protein: 42.5% (17/40) patients with increased leucocyte count and 10.70 x 10 9/L, in the untreated group, the white blood cell count in the death group was higher than that in the survival group, the difference was statistically significant (P0.05); 48.7% (19/39). The hypersensitive C reaction protein was elevated, the mass of the hypersensitive C reactive protein 7mg/L. (3) CKMB, the hypersensitive troponin T and the B type natriuretic peptide of the N terminal: the CKMB quality and the T increase of the hypersensitivity troponin in the patients with 88.8% (32/36) and 94.4% (34/36) respectively. In the receiving ECMO treatment group, the hypersensitive troponin protein of the death group was higher than the survival group, the difference was statistically significant. P0.05; N terminal B type natriuretic peptide in all patients increased in varying degrees, and the N terminal B type natriuretic peptide in the death group was higher than that of the survival group in the unaccepted ECMO treatment group. (4) electrocardiogram (ECG): 97.3% patients had abnormal electrocardiogram (57.8%), sinus tachycardia (52.6%), and various atrioventricular transmission. Conduction block (34.2%) and ventricular tachycardia (34.2%). (5) echocardiography: the main manifestations were left ventricular ejection fraction (71.7%), atrial or ventricular enlargement (28.2%), ventricular septum and left posterior wall thickening (20.5%). In the untreated group, left ventricular ejection fraction in the death group was lower than that in the survival group, the difference was statistically significant (P0.05).4, treatment: scores (.4). 97.5% and 87.5% of the patients received high dose hormone shock and gamma globulin treatment, 13 patients received ECMO treatment; the mortality rate in the unaccepted ECMO treatment group (48.1%) was higher than that in the ECMO treatment group (15.4%), the difference was statistically significant (P0.05).5, in 40 patients, 15 (37.5%) died, 23 (57.5%) patients survived, 2 patients were alive. Conclusion: there are various clinical manifestations of fulminant myocarditis in children, and the first symptoms are more common in the outside of the heart. The symptoms of the digestive system are the most common, so the early diagnosis is difficult. At present, the detection rate of Coxsackie virus (PCR detection) is greatly reduced, while the myocardial markers and the N terminal B natriuretic peptide are still diagnosed as fulminant myocarditis. Important signs: the increase of leukocyte count and the N terminal B natriuretic peptide, the drop in left ventricular ejection fraction may be a risk factor affecting the prognosis of children with fulminant myocarditis; the traditional treatment of fulminant myocarditis includes symptomatic support therapy, anti heart failure, shock resistance, antiarrhythmic, high-dose hormone shock and gamma globulin treatment, and ECMO The application of this method has greatly improved the success rate of rescue for children with fulminant myocarditis, and has become a reliable means to treat children with fulminant myocarditis.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R725.4

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