the stage based therapy ofcritically ill children with ev 71 infection课件

以病程分期為依據之兒童腸病毒加護照護 The Stage Based Therapy of Critically Ill Children with EV 71 Infection,林口長庚兒童醫院 兒童加護科 夏紹軒 吳昌騰 兒童心臟科 黃茂盛 鍾宏濤 兒童神經科 林光麟 王傳育 兒童呼吸胸腔科 黃健燊 兒童感染科 張鑾英 黃玉成 邱政洵 林奏延,A Cardiopulmonary disaster requiring multidisciplinary treatment,I. Outbreaks II. 臨床分期及其表現 III. 治療的考量 V. 結論,Outbreaks (1),民國八十七年五月初 一個一歲兩個月大的小女孩被帶到門診，主訴是 fever with oral ulcers and vesicles on hands, feet and knees. 母親對於小朋友的高燒不退、躁動不安、食慾減退、入睡困難、無力站立非常擔心。,Outbreaks (2),醫生說：這是典型手足口病症狀，只要吃一些退燒藥，多休息、多喝水就好了。 第二天，小女孩被帶回急診，已經發生意識不清、發紺等症狀，當時，急診醫師為她插上氣管內管，大量粉紅色泡沫狀液體從氣管內冒出。,Outbreaks (3),小女孩被送到 PICU. 發生心肺衰竭，CPR無效後，被宣布死亡。,I. Outbreaks II. 臨床分期及其表現 III. 治療的考量 V. 結論,Phases Based Therapy of Critical EV-71 Infection 腸病毒重症之臨床分期,第一期：上呼吸道感染手足口病 第二期：神經症狀腦膜腦脊髓炎 第三A期：高血壓肺水腫出血自主神經失調 第三B期：低血壓心臟衰竭？心肌炎？SIRS? 第四期：逐漸恢復神經後遺症,分期標的,Stage 1: Oral ulcer, skin rash, fever Stage 2: Neurological symptoms myoclonic jerk, limb weakness, seizure, consciousness disturbance Stage 3A: Elevated BP Stage 3B: Decreased BP, use of catecholamines Stage 4: Cessation of catecholamines.,Table A Severe Hypertension Criteria by Age,Modified from Hycan et al Task Force on Blood Pressure control in Children. Pediatrics 79:1, 1987.,Table B. Normal Blood Pressure by Age,Hazinski MF: Nursing Care of the Critically Ill Child, 2nd ed. St.Louis, Mo: Mosby Year Book; 1992,第一期：手足口病,持續約數天 可能發高燒 類手足口病Hand-Foot-Mouth disease 類皰疹性咽峽炎Herpangina 大多數病人可自然痊癒，無後遺症 手足水泡較典型手足口病小約針尖大小 高危險群可能向後期發展,第二期：腦膜腦炎,持續數天 包括睡眠易驚醒startling、手足抖動myoclonic jerk、肢體無力weakness 可能嘔吐、嗜睡 可能發生痙攣 腦脊髓液可能有發炎跡象亦可能無 到此仍可能自然痊癒，或許有後遺症,第三A期：高血壓肺水腫出血自主神經失調？,持續約數小時至一天左右 血壓上升為最早徵兆、高燒、心搏過150-200/min以上、呼吸急促、出冷汗。 高血糖(200mg/dl) 肺水腫、肺泡出血、血氧含量降低 神經症狀持續惡化，昏迷指數降低、四肢更無力,第三B期：低血壓：心臟衰竭,持續約二至七天 心搏速率漸降但血壓可能更低 肺水腫出血漸好轉但仍需呼吸器，自呼能力差 血糖正常化 神經症狀之變化：垂直眼震顫、斜視、肢體無力、抽筋等，此期間腦灌流可能變差造成缺氧缺血性腦病變。,第四期：逐漸恢復,持續？月？年 心臟功能幾乎完全恢復 肺功能可能不好但足堪負擔換氣，然而病人自呼、吞嚥功能不好有嚴重影響，所以仍需呼吸器支持。 漸漸甦醒，神經可能有嚴重後遺症 可能發生反覆性肺炎。,重症病例之前趨症狀及危險因子 I,重症病例前趨症狀 四肢反射性抖動 (myoclonic jerk) 嘔吐 嗜睡,中樞神經受侵犯之危險因子 年齡小於三歲 高燒超過39度 燒超過3天 嗜睡、抽筋、頭痛 嘔吐 高血糖(150mg/dl),重症病例之前趨症狀及危險因子 II,重症病例中肺水腫之危險因子 年齡小於三歲 高血糖(150mg/dl) 肢體無力 白血球升高 重症包含中樞神經受侵犯及肺水腫,Parameters Sequence Around PE,Parameters Sequence (2),I. Outbreaks II. 臨床分期及其表現 III. 治療的考量 V. 結論,When Patient Becomes Critically Ill?,Neurological deteriorates GCS9 Apnea, choke Unable to protect airway-loss of the ability to swallow and cough Paradoxical respiration Pulmonary edema/hemorrhagehypoxemia develops Cardiovascular system malfunctions: hypertension, tachycardia, or hypotension,Virus,SIRS,Cytokines,RV,LV,Neuromediator?,Change capillary permeability,Catecholamines,Diastolic dysfunction,Early, SVR,?Hypervolemia,?Systolic function,congestion,Late, SVR,Virus,SIRS,Cytokines,RV,LV,Neuromediator?,Change capillary permeability,Catecholamines,Diastolic dysfunction,Early, SVR,?Hypervolemia,?Systolic function,congestion,Late, SVR,Clonidine?,Vaccine?,IVIG?,Steroid?,PPV,-blocker?,vasopressor,Dopamine milrinone,Fluid restriction diuretics,Stage CNS Involvement General Treatment,1. Admit to PICU p.r.n. 2. Monitor BP, HR, sugar, ABG, e, coma scale 3. Intubate patient and provide mechanical ventilator for GCS9 or significant IICP (seldom noticed) 4. IVIG: dosage? 5. Fluid restriction:1/2-2/3 maintenance, 6. Furosemide for patients with high CVP 7. Invasive monitoring: CVP ABP?,Stage CNS Involvement Specific Treatment for CNS,Anticonvulsants to control seizure Keep head in midline position with 15-30 tilt Aggressively control body temperature Watch Increased ICP signs and give Mannitol or glycerol as needed Sedatives? midazolam, morphine or propofol Consult neurologists Monitoring: GCS, TCD, NIRS, ICP?, SjvO2?,Stage A: Treatment,Ristrict preload: Fluid restriction, diuretics Reduce afterload cautiously?: BP ,with normal cardiac contractility : vasodilator or -blocker: XNitroprusside? 0.5-4mcg/kg/min XEsmolol? 50-300mcg/kg/min Milrinone 0.25-0.75 mcg/kg/min Sedatives? midazolam, morphine or propofol Augment myocardium contractility Milrinone 0.25-0.75 mcg/kg/min Dobutamine 5-20 mcg/kg/min,Stage A: Treatment,Mechanically Ventilated with PEEP:6-8cmH2O Consider HFOV when hypoxemia and hemorrhage persist despite PEEP 8cm H2O or MAP 15cm H2O, or OI13 Change IVF to NS when glucose 200mg%, and shift to D2.5HS when glucose drops to 200mg% Anticipate the drop of BP when hyperglycemia corrects. Steroids? Central Antisympathetics?,Stage B Hypotension: treatment,Maintain adequate cerebral and vital organ perfusion during hypotension, optimize preload, afterload and myocardium contractility Inotropes dopamine 5-20mcg/kg/min epinephrine 0.05-0.4(?)mcg/kg/min A very HIGH infusion rate of inotropes may be needed to keep adequate BP 2. ECMO and ventricular assist device?,Stage B Hypotension: treatment,Wean ventilator as tolerated, switch back to conventional ventilator when MAP15cmH2O CNS evaluation: cerebral perfusion? Add glucose in IVF when sugar drops to about under 200mg% Start enteral nutrition ASAP when inotropes are tapered to low infusion rate.,Stage Convalescence-Treatment,Wean off inotropes Tracheostomy for ventilator dependent patients Chest care is mandatory to avoid aspiration pneumonia Swallowing disturbancetube feeding (gastric or duodenum) Rehabilitation Refer to respiratory care center or home care,Conclusion,The following actions are important in managing the