摘要目的 探讨危重症手足口病的循环障碍特点,分析治疗效果.方法 对22例危重症手足口病的临床特点尤其循环衰竭发生的规律、治疗及转归进行回顾性分析.结果 22例危重症手足口病患儿全部来自农村,脑炎22例；伴心肌损伤15例；22例危重症患儿均有交感神经兴奋期表现,其中高血压17例[(128±16)/(81±14) mm Hg(1 mm Hg=0.133 kPa)],22例入院时均有呼吸心率快表现.22例中14例出现血压下降[(61±12)/(33±12) mm Hg],并且由交感兴奋期很快进入此期,其中有13例患儿于高血压后1～21 h出现低血压,平均5h；1例于入院后6小时直接出现低血压；神经源性肺水肿有13例,均同时伴有休克表现；休克伴有心肌损伤13例(13/14),死亡5例均有心肌损害；出现休克的病例中12例Glasgow评分7分以下(12/14),部分有明显的心电图改变,有3例休克患儿血脑钠肽明显增高.血乳酸升高19例,其中14例休克患儿早期乳酸均升高,死亡病例血乳酸持续高水平.休克患儿中10例CRP明显增高[(31.76±26.15) mg/L].磁共振检查9例,有6例明显异常.在对症支持处理的基础上,以小剂量激素、大剂量丙球冲击,机械通气、循环支持及脱水降颅压为主的综合性治疗.其中血管活性药物以米力农、多巴胺及多巴酚丁胺等为主,部分病例使用了去甲肾上腺素,9例行血液净化治疗；19例行气管插管机械通气治疗,平均持续约20.58 d,最长90d.17例患儿治愈或好转出院；5例患儿经抢救无效死亡,其中3岁以内占4例.17例存活病例中单用米力农1例；多巴胺与米力农联合治疗9例；3例给予硝普钠或多巴酚丁胺等治疗；4例未见明显血压改变,故未给予血管活性药物.米力农和多巴胺强心升压不明显时给予单用或同时应用去甲肾上腺素治疗5例,其中3例治愈或好转出院,2例死亡.死亡5例患儿因应用大剂量多巴胺或去甲肾上腺素后血压仍难以维持正常,故给予扩容治疗,但效果不佳.结论 循环功能衰竭目前已成为危重症手足口病的主要死亡原因,早期识别危重患儿并给予恰当的循环支持尤其血管活性药是降低病死率的关键.

abstractsObjective To investigate the characteristics of circulatory disturbance and treatment of severe hand-foot-and-mouth disease (HFMD).Method The clinical characteristics,laboratory findings,therapy and outcome of 22 severe HFMD patients were retrospectively analyzed.Result All the 22 severe HFMD patients came from the countryside.All these patients had encephalitis.Fifteen cases had myocardial injury.All had symptoms of sympathetic excitation and 17 cases had hypertension [( 128 ± 16 )/( 81 ± 14 ) mm Hg(1 mm Hg =0.133 kPa)].Fourteen cases had exacerbation with rapid decline of blood pressure [(61 ± 12)/(33 ±12) mm Hg].In cardiorespiratory failure stage,13 patients had neurogenic pulmonary edema accompanied by circulatory failure and 12 cases had a lower glasgow scores ( less than 7 ).Myocardial injury and ECG change were found in some cases.Inotropic and pressor drugs were given in patients with circulatory collapse.Five cases received fluid resuscitation due to refractoriness to inotropic drugs. Nine patients received blood purification. Seventeen survived and 5 cases died due to circulatory failure.Conclusion Circulation failure of severe HFMD is the main cause of death. Early and appropriate circulation support is very important to reduce mortality.