小儿心源性休克的临床分析

目的分析小儿心源性休克(CS)的临床特点和预后。方法2002年1月至2005年12月本院PICU收治的非心脏病近期手术所致CS患儿19例。回顾分析临床表现、心电图、胸片、超声心动图特点及与预后的关系。结果小儿CS临床表现以呼吸道、消化道症状为主,缺乏特异性。病死率68.4%,其中61.5%死于入院24h内,平均死亡时间为入院后31.5h。死亡的原发病为心肌炎(58例),先心病(56例),心肌病(22)和感染性心内膜炎(11)。直接死亡原因分别是心脏泵功能衰竭、心律失常各4例,心脏泵功能衰竭与心律失常共同作用5例。超声心动图的血流动力学参数LVEF、SVI、LVEDVI、LVESVI、CI在生存者和死亡者之间差异无显著性(P>0.05)。并发DIC及心跳呼吸骤停的病死率分别是100%及75%。肝、肾功能异常,代谢性酸中毒的严重度与病死率无关。结论小儿CS病死率高,尤其在CS早期,并发DIC及心跳呼吸骤停者预后更差。致死的主要原因是心肌炎、心肌病、先心病等原发病导致心脏泵功能衰竭或和心律失常。超声心动图对原发病的诊断起十分重要的作用,应早期常规检查,但其血流动力学变化不能作为判断预后的指标。传统治疗方法效果不佳,在国内应尽快采用VAD、BiVAD、ECMO等技术救治暴发性心肌炎所致CS,以挽救患儿生命。

Clinical analysis of cardiogenic shock in pediatric patients

Objective To explore the clinical features and prognosis of cardiogenic shock (CS) in pediatric patients. Methods Nineteen patients with CS admitted to our PICU from January 2002 to December 2005 were included in the study. The clinical data, the records of electrocardiogram, chest radiograph, echocardiograph were reviewed, and the prognostic value of these indexes were analyzed. Results The clinical manifestations of pediatric CS were respiratory or gastrointestinal systems without specific features. The mortality was 68.4%, and among them 61.5% died within 24 hrs after admission. The time of the death was on average 31.5 hrs after admission. The underlying diseases were fulminant acute myocarditis (5/8), congenital heart disease (5/6), cardiomyopathy (2/2), and infect endocarditis (1/1). The causes of death were cardiac pump failure (4), arrhythmias (4) and cardiac pump failure with arrhythmias (5). There were no significant differences in the hemodynamic parameters of echocardiography such as LVEF, SVI, LVEDVI, LVESVI, CI between patients who survived and those who died. The mortality of CS with DIC or cardiopulmonary arrest was 100% and 75%, respectively. The mortality was not related to the severity of liver/renal dysfunction or metabolic acidosis. Conclusion The mortality of pediatric CS was high, especially soon after admission. The patients with CS and DIC or cardiopulmonary arrest had the poorest prognosis. The main causes of death were cardiac pump failure and/or arrhythmias in the patients with myocarditis, congenital heart disease and cardiomyopathy. Echocardiography was the most useful noninvasive diagnostic mean and it should be used as an early routine examination. However the parameters could not be regarded as prognosis-related. Traditional management was not useful for treating CS patients. The techniques of VAD, BiVAD and ECMO should be introduced as soon as possible for treating CS originated from fulminant acute myocarditis in order to improve the prognosis.