重症严重急性呼吸综合征的机械通气管理

重症严重急性呼吸综合征(SARS)可迅速发展为急性呼吸窘迫综合征(ARDS) ,现对我们ICU收治的6例重症SARS病例实施有创机械通气治疗的经验作回顾性分析。对象与方法　病例的基本情况,见表1,其中第1例为广东省首例SARS ,于2 0 0 2年11月16日发病;所有患者恢复期血清SARS CoV抗体IgG均为强阳性。表1　重症SARS患者一般情况序号性别年龄(岁)潜伏期(d)既往病史1男45不详无2女5 0 13支气管哮喘3男5 1不详2型糖尿病、高血压病4男42 3慢性支气管炎5男3 47无6男5 7 9无　　机械通气治疗:使用麻醉气管插管法,先后使用镇静剂咪唑安定0 0 4…     

传染病寄生虫病（20050001-20050096）

广东省医务人员SARS危险因素的流行病学研究，医务人员高暴露人群严重急性呼吸综合征隐性感染与工作强度和工种的相关性研究，2004年广州市4例散发严重急性呼吸综合征特点分析，225例严重急性呼吸综合征临床诊断病例临床特点分析，258例严重急性呼吸综合征康复期患者肺功能与影像学动态随访与分析。     

2004年中国首例社区获得性散发严重急性呼吸综合征的临床分析

目的　了解 2 0 0 4年我国首例社区获得性散发严重急性呼吸综合征 (SARS)病例的流行病学、临床、病原学检查特点及预后转归。方法　对患者流行病学及临床资料进行回顾性分析 ,并采用酶联免疫吸附试验 (ELISA)及免疫荧光试验检测SARS IgM /IgG抗体 ,荧光聚合酶链反应 (PCR)测定SARS CoVRNA。结果　患者 2 0 0 3年 12月 16日以发热起病 ,持续 8d ,有咳嗽、气促等症状 ,白细胞及T淋巴细胞计数降低 ,影像学检查示双肺密度增高影。起病前无流行病学依据 ,81名接触者均未出现发热等异常情况。 12月 2 7日被诊断为SARS疑似病例 ,2 0 0 4年 1月 5日确诊为SARS。经对症支持等综合治疗痊愈出院。对多份血清进行平行检测 ,SARS IgM阴转阳 ,滴度呈 4倍以上升高 ,SARS IgG在起病一周内出现 ,抗体滴度很快呈现 4倍以上升高。在咽拭子中检测出SARS CoVRNA。中和试验结果阳性。结论　该患者为 2 0 0 4年我国首例社区获得性散发SARS确诊病例 ,其无流行病学依据 ,临床表现不重 ,抗体出现早 ,病情恢复快。     

关于严重急性呼吸综合征的诊断标准的探讨

传染性非典型肺炎即严重急性呼吸综合征(SARS)因其极强的传染性以及病情的急剧发展而引起严重关注。早期正确诊断无疑是SARS防治的重要环节，患得以及时治疗，减少社会传播。SARS的诊断主要依据流行病学和临床资料，但是其临床表现往往缺乏特异性，故常易与各种急性感染性或非感染性呼吸道疾病相混淆。     

无创正压通气在严重急性呼吸综合征呼吸衰竭中的应用

临床实践表明，有23％～32％的严重急性呼吸综合征（SARS）患者可能合并急性肺损伤和（或）急性呼吸窘迫综合征的呼吸衰竭，需机械通气辅助呼吸。应用低潮气量的肺通气保护策略进行有创机械通气治疗SARS呼吸衰竭已得到广泛认同。但无创正压通气（NPPV）的应用价值在国际上尚存争议。在SARS暴发早期，中华医学会出版的相关指南中推荐尽早应用NPPV以改善患者的缺氧状态。     

佛山地区首批SARS病例血清学调查支持病原体为冠状病毒

目的 求证佛山地区首批SARS患者的病原体。方法 以SARS冠状病毒全病毒裂解液作抗原，利用ELISA技术检测佛山地区首批出现急性呼吸窘迫综合征并具有明显传染特征的SARS康复患者和患者居住地“健康者”血清中抗SARS冠状病毒抗体。结果 4组有流行病学关系的19例SARS患者血清中抗SARS冠状病毒抗体全部阳性，而400例患者居住地的“健康者”血清中抗SARS冠状病毒抗体则全部阴性。结论 佛山地区首批SARS病例血清学病原体调查结果完全支持SARS的病原体为SARS冠状病毒；抗SARS抗体IgG在SARS康复者血清中至少可存在6个月。     

重症急性呼吸综合征的诊断与治疗

重症急性呼吸综合征(SARS)是一种新出现的烈性传染病，其临床表现不典型，主要通过影像学和实验室检查进行诊断；目前SARS尚无特效疗法，治疗方法主要包括药物治疗如抗病毒药、抗生素、激素治疗，呼吸机的应用，血清治疗及中西医结合治疗等方法。     

15例严重急性呼吸综合征患者心脏骤停原因的探讨

目的 探讨严重急性呼吸综合征(SARS)患心脏骤停的原因。方法 对15例SARS心脏骤停病例的流行病学、临床表现、实验室检查、影像学检查及治疗措施，进行回顾性分析。结果 15例SARS心脏骤停病例，平均年龄60岁；8例有明确的sARS患接触史，其中6例属于家庭内密切接触发病；8例无基础疾病；8例精神异常紧张；9例心脏骤停于病情稳定时；4例于排便后心脏骤停；10例患心肌酶异常；13例双侧肺部有斑片状阴影；5例心脏骤停前有心肌缺血及心律失常的心电图表现。结论 SARS患心脏骤停的原因可能为：(1)SARS病毒损伤肺组织引起机体缺氧，导致心电不稳定。(2)SARS病毒直接损伤心肌细胞和(或)心脏传导系统。(3)SARS病毒感染加重原有心肌病变及传导障碍。(4)精神异常紧张，儿茶酚胺过度释放，导致心电不稳定。(5)排便加重缺氧，诱发心律失常(心室颤动等)而导致心脏骤停。     

2004年北京首例严重急性呼吸综合征病例临床分析

目的　总结 2 0 0 4年 4月北京首例严重急性呼吸综合征 (SARS)病例的临床特点 ,为今后临床医师及时有效准确诊断SARS疑似病例并进行相应鉴别诊断提供参考线索。方法　对 1例外院转入病例的临床资料进行分析 ,并总结其临床特点。结果　 (1)地区性首例SARS患者的诊断难度大 ,短期内难以确定其流行病学史 ;(2 )SARS患者发病早期可表现出一般肺炎的特点 ,无特征性改变。结论　重视流行病学调查 ,早发现、早报告、早隔离和早治疗 ,对改善SARS患者的预后和控制其蔓延有着十分重要的意义。     

严重急性呼吸综合征临床特征与X线动态变化

严重急性呼吸综合征(SARS)是一种新出现的具有高度传染性的疾病，无特异诊断和治疗方法。我们对55例SARS患的临床特征和影像表现进行连续的对比分析，以助早期诊断和治疗。     

严重急性呼吸综合征所致呼吸衰竭及无创通气治疗

目的　回顾性总结严重急性呼吸综合征 (SARS)并发呼吸衰竭患者的血气特点 ,探讨应用无创正压通气 (NPPV)治疗的策略。方法　 2 0 0 3年 4月 2 2日～ 5月 1日 ,12 0例临床符合SARS诊断标准的患者入住北京地坛医院 (SARS专科医院 )的 4个病区 ,30例患者 (占 2 5 % )在病程中出现呼吸衰竭 ,达到急性肺损伤 (ALI)和 (或 )急性呼吸窘迫综合征 (ARDS)的诊断标准。 2 8例应用双水平气道正压通气 (BiPAP)。主要观察指标 :(1)住院期间的血气分析、脉搏容积血氧饱和度 (SpO2 )及呼吸频率 ,特别是上机前、上机后 1h及撤机后的结果 ;(2 )放射学检查或临床提示住院后新出现的气胸、纵隔气肿、心包积气及皮下气肿 ;(3)应用无创通气的天数 ;(4 )需气管插管行有创通气的患者数 ;(5 )患者的病死率 ;(6 )一线医务人员因护理治疗无创通气SARS患者而感染SARS的情况。结果统计 30例患者在整个病程中的动脉血二氧化碳分压 (PaCO2 )变化情况 ,16例 (5 3% )患者出现CO2 潴留 ,PaCO2为 4 5～ 5 6mmHg ,平均 (4 8± 4 )mmHg。NPPV治疗后动脉血氧分压 (PaO2 )、SpO2 、氧合指数及呼吸频率均显著改善 (P均 <0 0 1) ,但pH及PaCO2 的变化并不明显。 18例患者成功撤机 ,应用NPPV的时间为5～ 30d ,平均 (10± 6 )d。除 1例不能耐受BiPAP     

Clinical significance of hepatic derangement in severe acute respiratory syndrome

ABM: Elevation of alanine aminotransferase (ALT) level is commonly seen among patients suffering from severe acute respiratory syndrome (SARS). We report the progression and clinical significance of liver derangement in a large cohort of SARS patient. METHODS: Serial assay of serum ALT was followed in patients who fulfilled the WHO criteria of SARS. Those with elevated ALT were compared with those with normal liver functions for clinical outcome. Serology for hepatitis B virus (HBV) infection was checked. Adverse outcomes were defined as oxygen desaturation, need of intensive care unit (ICU) and mechanical ventilation and death. RESULTS: Two hundred and ninety-four patients were included in this study. Seventy (24%) patients had elevated serum ALT on admission and 204 (69%) patients had elevated ALT during the subsequent course of illness. Using peak ALT >5xULN as a cut-off and after adjusting for potential confounding factors, the odds ratio of peak ALT >5x ULN for oxygen desaturation was 3.24 (95%CI 1.23-8.59, P= 0.018), ICU care was 3.70 (95%CI 1.38-9.89, P= 0.009), mechanical ventilation was 6.64 (95%CI 2.22-19.81, P = 0.001) and death was 7.34 (95%CI 2.28-24.89, P= 0.001). Ninety-three percent of the survived patients had ALT levels normalized or were on the improving trend during follow-up. Chronic hepatitis B was not associated with worse clinical outcomes. CONCLUSION: Reactive hepatitis is a common complication of SARS-coronavirus infection. Those patients with severe hepatitis had worse clinical outcome.     

Clinical significance of hepatic derangement in severe acute espiratory syndrome

AIM: Elevation of alanine aminotransferase (ALT) level iscommonly seen among patients suffering from severe acute respiratory syndrome (SARS). We report the progression and clinical significance of liver derangement in a large cohort of SARS patient.METHODS: Serial assay of serum ALT was followed in patients who fulfilled the WHO criteria of SARS. Those with elevated ALT were compared with those with normal liver functions for clinical outcome. Serology for hepatitis B virus (HBV) infection was checked. Adverse outcomes were defined as oxygen desaturation, need of intensive care unit (ICU) and mechanical ventilation and death.RESULTS: Two hundred and ninety-four patients wereincluded in this study. Seventy (24%) patients had elevatedserum ALT on admission and 204 (69%) patients hadelevated ALT during the subsequent course of illness. Using peek ALT ＞5xULN as a cut-off and after adjusting for potential confounding factors, the odds ratio of peek ALT ＞5x ULN for oxygen desaturation was 3.24 (95%CI 1.23-8.59, P = 0.018), ICU care was 3.70 (95%CT 1.38-9.89, P = 0.009), mechanical ventilation was 6.64 (95%CI 2.22-19.81, P = 0.001) and death was 7.34 (95%CI 2.28-24.89, P = 0.001). Ninety-three percent of the survived patients had ALT levels normalized or were on the improving trend during follow-up. Chronic hepatitis B was not associated with worse clinical outcomes. CONCLUSION: Reactive hepatitis is a common complication of SARS-coronavirus infection. Those patients with severehepatitis had worse clinical outcome.     

北京地区250例严重急性呼吸综合征患者临床分析

目的　探讨严重急性呼吸综合征 (SARS)的流行病学特征、临床表现、实验室检查、治疗及预后等特点。方法　回顾性分析北京地坛医院 2 50例SARS患者的临床资料。结果　 2 50例患者的平均年龄 (3 6± 16)岁 ,男 110例 (44 0 % ) ,女 14 0例 (56 0 % )。潜伏期平均 (8± 7)天。主要临床表现 :发热 (10 0 0 % )、咳嗽 (72 8% )、乏力 (70 0 % )。外周血白细胞计数降低者占 2 7 2 % ,淋巴细胞比例降低者占 64 2 %。CD+ 4和CD+ 8计数降低者分别占 91 4%、80 6%。动脉血氧饱和度 (SaO2 )低于 97%者162例 (64 8% )。血清丙氨酸转氨酶 (ALT)升高者 45 2 % ,天冬氨酸转氨酶 (AST)升高者 2 9 4% ,乳酸脱氢酶 (LDH)升高者 42 1% ,肌酸激酶 (CK)升高者 18 3 %。恢复期血清SARS病毒特异性抗体IgG阳性率 69 9%。采用综合治疗 ,使用抗生素、抗病毒药物、激素及免疫增强剂。需要呼吸支持者 196例 ,气管插管或切开机械通气支持治疗者 8例 ,重症患者 81例 (3 2 4% ) ,死亡 2 5例。结论　SARS传染性较强 ,中青年人群患病为主 ,有特征性临床表现 ,采用综合治疗 ,多数患者可取得较好疗效     

安徽省阜阳市首例H5N1型人禽流感临床报告

目的了解人感染高致病性H5N1型禽流感流行病学和临床学特征及防治手段。方法对本院收治的1例人感染高致病性H5N1型禽流感病例的相关资料进行回顾性分析。结果患者为26岁年轻孕妇,有病、死家禽接触史,临床表现为以急性呼吸窘迫综合征为主的全身多器官功能障碍,治疗上采取了以机械通气为主的综合性措施,治愈出院。结果提高对人感染高致病性H5N1型禽流感诊断的警惕性,及早干预是降低病死率的关键环节。     

SARS: hospital infection control and admission strategies

Nosocomial clustering with transmission to health care workers, patients and visitors is a prominent feature of severe acute respiratory syndrome (SARS). Hospital outbreaks of SARS typically occurred within the first week after admission of the very first SARS cases when the disease was not recognized and before isolation measures were implemented. In the majority of nosocomial infections, there was a history of close contact with a SARS patient, and transmission occurred via large droplets, direct contact with infectious material or by contact with fomites contaminated by infectious material. In a few instances, potential airborne transmission was reported in association with endotracheal intubation, nebulised medications and non-invasive positive pressure ventilation of SARS patients. In all SARS-affected countries, nosocomial transmission of the disease was effectively halted by enforcement of routine standard, contact and droplet precautions in all clinical areas and additional airborne precautions in the high-risk areas. In Hong Kong, where there are few private rooms for patient isolation, some hospitals have obtained good outcome by having designated SARS teams and separate wards for patient triage, confirmed SARS cases and step-down of patients in whom SARS had been ruled out. In conclusion, SARS represents one of the new challenges for those who are involved in hospital infection control. As SARS might re-emerge, all hospitals should take advantage of the current SARS-free interval to review their infection control programmes, alert mechanisms, response capability and to repair any identified inadequacies.     

78例传染性非典型肺炎病例临床分析

目的　分析传染性非典型肺炎 (世界卫生组织又称严重急性呼吸综合征 ,SARS)患者的临床特点 ,并对其诊断标准和治疗方法进行探讨。方法　对广州呼吸疾病研究所 2 0 0 2年 12月 2 2日至 2 0 0 3年 3月 31日收治的 78例SARS患者的临床、实验室、影像学资料进行回顾性分析。结果78例SARS患者 :男 4 2例 ,女 36例 ;年龄 2 0～ 75岁 ,平均 (37 5± 11 6 )岁 ;医务人员 4 4例 (5 6 % )。临床症状包括 :发热 (10 0 % )、咽痛 (17% )、咳嗽 (88% )、气促 (80 % )、畏寒 (5 9% )、肌肉酸痛 (41% )。血常规 :白细胞 (WBC) <4 0× 10 9/L 12例 (15 % ) ,WBC(4 0～ 10 0 )× 10 9/L 4 9例 (6 3% ) ,WBC >10 0× 10 9/L 17例 (2 2 % ) ,平均为 (7 6± 5 0 )× 10 9/L ;中性粒细胞为 0 75± 0 14 ,淋巴细胞 0 18±0 11。胸部X线和CT显示肺部斑片状阴影 ,短期内病灶增多 ,累计单侧 2 3例 (30 % )、双侧 5 2例(6 7% )。分析医护人员被感染途径 ,提示本病具有较强的飞沫近距离传染特性。出现急性肺损伤(ALI) 37例 (47% ) ,其中发展为急性呼吸窘迫综合征 (ARDS) 2 1例。 7例死亡患者均为ARDS合并有多器官功能衰竭综合征 (MODS)。结论　流行病接触史、发热、X线肺炎征及白细胞计数正常或减少是诊断本病的临床依据。     

Myocardial localization of coronavirus in COVID‐19 cardiogenic shock

We describe the first case of acute cardiac injury directly linked to myocardial localization of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in a 69‐year‐old patient with flu‐like symptoms rapidly degenerating into respiratory distress, hypotension, and cardiogenic shock. The patient was successfully treated with venous‐arterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation. Cardiac function fully recovered in 5 days and ECMO was removed. Endomyocardial biopsy demonstrated low‐grade myocardial inflammation and viral particles in the myocardium suggesting either a viraemic phase or, alternatively, infected macrophage migration from the lung.