本文選題：兒童 + 暴發(fā)性心肌炎　； 參考：《浙江大學(xué)》2017年碩士論文

【摘要】：研究目的:通過(guò)總結(jié)兒童暴發(fā)性心肌炎的臨床特點(diǎn)及治療措施,為兒童暴發(fā)性心肌炎的早期診斷及治療提供臨床依據(jù);并為進(jìn)一步大樣本隨機(jī)對(duì)照研究打下基礎(chǔ)。研究方法:回顧性分析浙江大學(xué)醫(yī)學(xué)院附屬兒童醫(yī)院2009年03月至2016年12月臨床診斷暴發(fā)性心肌炎并收治住院的40例患者的臨床資料,根據(jù)是否接受體外膜肺氧合(Extracorporeal membrane oxygenation,ECMO)治療,將患者分為未接受 ECMO治療組(27例)和接受ECMO治療組(13例),在兩個(gè)治療組中,根據(jù)患者預(yù)后,再將其分為死亡組和存活組,應(yīng)用SPSS17.0統(tǒng)計(jì)軟件分析,對(duì)患者的一般情況、臨床表現(xiàn)、輔助檢查結(jié)果、治療方法及轉(zhuǎn)歸等方面進(jìn)行歸納總結(jié)。結(jié)果:1、一般資料:40例FMC患兒,男性22例(55%),女性18例(45%),年齡2個(gè)月至13歲,平均發(fā)病年齡(7.50±3.85)歲;至我院就診時(shí)間最短8小時(shí),最長(zhǎng)10天,中位就診時(shí)間3天。2、臨床表現(xiàn)及體征:首發(fā)癥狀以消化系統(tǒng)癥狀(72.5%)最常見(jiàn),14例(35%)有前驅(qū)上呼吸道感染癥狀,20例(50%)患者有發(fā)熱表現(xiàn);臨床體征以心音低鈍(70%)及肝臟腫大(40%)最常見(jiàn)。3、輔助檢查結(jié)果:(1)病原學(xué)檢查:25例患者行柯薩奇病毒PCR檢測(cè),結(jié)果均為陰性。(2)白細(xì)胞計(jì)數(shù)與超敏C反應(yīng)蛋白:42.5%(17/40)患者白細(xì)胞計(jì)數(shù)升高,中位白細(xì)胞計(jì)數(shù)10.70×10＾9/L,在未接受ECMO治療組中,死亡組白細(xì)胞計(jì)數(shù)高于存活組,差異有統(tǒng)計(jì)學(xué)意義(P0.05);48.7%(19/39)患者超敏C反應(yīng)蛋白升高,中位超敏C反應(yīng)蛋白7mg/L。(3)CKMB質(zhì)量、超敏肌鈣蛋白T及N末端B型利鈉肽原:分別有88.8%(32/36)和94.4%(34/36)的患者CKMB質(zhì)量及超敏肌鈣蛋白T升高,在接受ECMO治療組中,死亡組超敏肌鈣蛋白T高于存活組,差異有統(tǒng)計(jì)學(xué)意義(P0.05);所有患者N末端B型利鈉肽均有不同程度升高,且在未接受ECMO治療組中,死亡組N末端B型利鈉肽高于存活組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。(4)心電圖:97.3%患者心電圖存在異常,主要表現(xiàn)為ST段改變(57.8%),竇性心動(dòng)過(guò)速(52.6%)、各型房室傳導(dǎo)阻滯(34.2%)及室性心動(dòng)過(guò)速(34.2%)。(5)超聲心動(dòng)圖:主要表現(xiàn)為左室射血分?jǐn)?shù)降低(71.7%),心房或心室擴(kuò)大(28.2%),室間隔及左室后壁增厚(20.5%)等;在未接受ECMO治療組中,死亡組左室射血分?jǐn)?shù)低于存活組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。4、治療:分別有97.5%和87.5%的患者接受大劑量激素沖擊和丙種球蛋白治療,13例患者接受ECMO治療;未接受ECMO治療組的死亡率(48.1%)高于接受ECMO治療組(15.4%),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。5、轉(zhuǎn)歸:40例患者中,15例(37.5%)患者死亡,23例(57.5%)患者存活,2例患者出院后轉(zhuǎn)康復(fù)治療。結(jié)論:兒童暴發(fā)性心肌炎臨床表現(xiàn)多樣,首發(fā)癥狀多以心外表現(xiàn)多見(jiàn),其中消化系統(tǒng)癥狀最常見(jiàn),故早期診斷比較困難;目前柯薩奇病毒(PCR檢測(cè))檢出率大大降低,而心肌標(biāo)志物及N末端B型利鈉肽仍是診斷暴發(fā)性心肌炎的重要標(biāo)志;白細(xì)胞計(jì)數(shù)及N末端B型利鈉肽的升高、左室射血分?jǐn)?shù)的下降可能是影響兒童暴發(fā)性心肌炎預(yù)后的危險(xiǎn)因素;暴發(fā)性心肌炎傳統(tǒng)的治療包括對(duì)癥支持治療、抗心衰、抗休克、抗心律失常、大劑量激素沖擊及丙種球蛋白治療,而ECMO的應(yīng)用,大大提高了兒童暴發(fā)性心肌炎的搶救成功率,成為救治兒童暴發(fā)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.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R725.4

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本文編號(hào)：1787607