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    小兒重癥支原體肺炎28例臨床分析
    關鍵字:分析,臨床,KL,MN,IJ,GH,CD,EF,OP,QR, 發布時間:2011-08-21

    籃董:墮筮途壟 CNl~FsFcOMMUNI什Docroes dxJL重癥支原體肺炎28例臨床分析 張玉玲 472500河南靈寶市第一人民醫院 摘要目的:了解小兒支原體肺炎的臨 床特點及常見并發癥,提高診斷及治療水 平。方法:對28例重癥支原體肺炎 (MPP)進行回顧性分析。結果:28例均 有發熱,咳嗽表現,合并胸腔積液8例。肺 不張6例,肺出血l例。19例合并肺外 并發癥。結論:小兒重癥支原體肺炎常合 并胸腔積液、肺不張、肺外并發癥多見心 肌及肝功能受損。抗炎療效不佳者可聯 合應用腎上腺皮質激素及丙種球蛋白。 關鍵詞肺炎支原體肺炎重癥臨 床分析 doi:10.3969/j.issn.1007—614x.2010. 26.00l 資料與方法 2005年9月~2009年5月收治重癥 支原體肺炎28例,均符合重癥肺炎診斷 標準…。男18例,女10例,年齡l—15 歲,病程5—57天。 臨床表現:28例中25例(89%)為急 性起病,發病至就診時間平均5天,以咳 嗽、喘息起病,很快出現發熱,體溫38— 40℃,熱型不規則,持續3—14天,8例出 現呼吸困難(其中6例為嬰幼兒),另3 例(1l%)發病較緩慢,發病至就診平均 11天。6例(2l%)肺部聽到干濕性噦音 (均為3歲以下患兒),8例(28.5%)肺部 有實變體征(均為3歲以上息JL)。l例 氣胸。 并發癥及肺外表現:出現惡心、嘔吐、 腹痛、腹瀉者lO例,多為3歲以下嬰幼 兒。尿檢驗有蛋白、紅細胞者4例,其中 2例腎功能不全,BUN、Cr增高。出現心 引起內源性催產素分泌減少,引起宮縮期 延長和宮縮強度減弱,需使用催產素靜滴 補充。 綜上所述,o.075%羅哌卡因復合 1.5斗g/ml芬太尼在行走性硬膜外分娩鎮 痛中是安全有效的,不僅明顯減輕產痛、 有效控制應激反應,而且所有產婦均能下 床自由行走和自主排尿。對產程、官縮無 明顯影響.對胎兒無影響,可以提高陰道 自然分娩率和減少胎兒酸中毒。在分娩 鎮痛中,一旦出現任何因素引起胎心改 力衰竭者8例,均為3歲以下患兒,心肌 受損10例,出現心律不齊、心音低鈍,心 電圖顯示竇性心動過速、sT—T改變、房 性及搴性早搏、房竄傳導阻滯等,心肌酶 學顯示CK、CKMB、DH]增高。肝功能異 常3例,皮膚損害3例,出現斑丘疹或蕁 麻疹。神經系統損害2例,表現頭痛、嘔 吐、嗜睡、驚厥,腦電圖顯示彌漫性慢波, 測定腦脊液2例,蛋白陽性,細胞數略高, 糖及氯化物IE常。28例中2個臟器受損 者lO例,3個臟器受損者12例,3個以上 臟器受損者3例。 實驗室檢查:28例疵清MP—IgM抗 體均陽性。血培養8例均陰性。血白細 胞計數升高11例,血沉增快13例,CRP 升高7例。 胸部x線檢查:28例均拍胸片,顯示 單側或雙側問質性肺炎8例,均為3歲以 下嬰幼兒,其余均顯示單側或雙側肺斑片 或大葉性肺炎。合并胸腔積液5例,肺不 張4例,氣胸1例。 治療方法:入院后根據病情給予吸 氧、降溫、鎮靜、強心、平喘、止咳等對癥治 療。病原學未確定前,給頭孢曲松鈉或頭 孢拉定等治療,多無效。病原學確定后用 阿奇霉素或紅霉素治療,療程2~6周,同 時用地塞米松3—5mg/kg,其中8例應用 大劑量丙種球蛋白400rag/(kg?日),3 天。 結果 一般用藥3—7天熱退,咳嗽緩解,心 臟癥狀3~10天消失,心肌酶學2周后恢 復正常。神經系統癥狀5—6天改善。肝 功能10天后正常。皮膚損害3~4天消 失。尿檢l周后正常,BUN、Cr,5—10天 正常。胃腸道癥狀閑大環內酯類本身的 副反應,因而部分患兒持續時間長達2 周。1例氣胸轉外科。x線檢查:間質性 變,胎兒官內窘迫時應當機立斷終止自然 分娩行剖宮產術,以確保母嬰安全。 參考文獻 1王義琳,產科鎮痛的近期發展.國外醫學? 麻醉學與復蘇分冊.2000,21:53. 肺炎大多于2周內吸收,大葉性肺炎3— 6周痊愈,2例肺不張者均超過6周。所 有病例均治愈。 討論 兒童蕈癥支原體肺炎特點:支原體肺 炎一般起病較緩,多在秋冬季起病。臨床 主要表現為干咳、發熱,肺部體征多不明 顯,而影像學改變較多。本組28例則表 現為起病急,癥狀重、病程長,肺外癥狀 多,尤其嬰幼兒,且年齡越小,呼吸系統癥 狀越明顯,肺外系統受損越多、越重,年長 兒多表現為頑同性咳嗽,而肺部體征不明 顯,也均有不同程度的肺外系統改變,且 病程長,而受損的肺部系統以心肌損害最 為常見,其次為消化系統。 目前重癥支原體肺炎尚無統一的診 斷標準。臨床出現下列表現:起病急,發 熱,劇咳,喘息,呼吸困難,肺外多系統受 損,合并全身炎癥綜合征,x線顯示嚴重 的問質性肺炎,或大葉性肺炎及肺不張或 胸腔積液,病程長,單用大環內酯類療效 不佳,應考慮到重癥支原體肺炎的可能, 從而盡早做出診斷。抗生素首選阿奇霉 素,應足劑量,足療程(2—6周)。部分肺 部炎癥吸收緩慢者叮采取序貫療法(用 藥3天,停3天)。以減少不良反應發生。 對于霉癥及并發癥較多,病程長短考慮有 支原體耐藥的町能,可聯合使用腎上腺皮 質激素,丙種球蛋白以抑制免疫炎癥反 應,達到治療日的B-。 總之,加強對本病的認識,及早診斷 并聯合治療對患兒預后至關重要。 參考文獻 1胡亞美,江載芳,諸福棠.實用兒科學[M】. 北京:人民衛生出版社,2002:1204一1205. 2趙順英,等.兒童重癥支原體肺炎ll例臨 床分[J].中國實用兒科雜志,2003,18(7): 414—416. 2抗燕南,莊心良,蔣豪,等.當代麻醉學.第1 版.上海:上海科學技術出版社,2002:1444 —1454. 3范永利,趙觀麗,高瑞珍,等.羅哌卡因復合 芬太尼用于產婦自控硬膜外分娩鎮痛的可 行性.中華麻醉學雜志.2001,21:659—662. 褒1分娩方式、倦產素使用情囂【倒f%)】 r ,。P‘n05。 。 盛 82中國社區醫師?醫學專業2010年第2B期(簟12卷總第251期) 萬方數據 換頁

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