目的 探讨儿童甲型H1N1流感重症与危重症的不同临床特点及患儿发展成为重症、危重症的相关因素.方法 将2009年10月1日 - 2010年01月15日确诊并收住院的甲型H1N1流感患儿76例分成2组:重症组60例与危重症组16例,比较分析两组临床特征.结果 重症组平均年龄(2.91 ± 2.26)岁,显著低于危重症组的(4.68 ± 4.35)岁(P ＜ 0.05);重症组住院时间(7.75 ± 3.06)d,显著短于危重症组的(19.6 ± 7.72)d(P ＜ 0.05);重症组混合细菌感染以肺炎链球菌为主,危重症组为金黄色葡萄球菌为主;重症组有18.3%并存基础疾病,显著少于危重症组的56.3%(P ＜ 0.05),重症组并存基础疾病以哮喘多见,危重症组以缺铁性贫血多见,次之是脑性瘫痪和先天性心脏病.重症组氧合指数为307.18 ± 55.73,显著高于危重症组的187.50 ± 73.62(P ＜ 0.05);重症组血清前白蛋白和白蛋白显著高于危重症组(P ＜ 0.05),而肌酸激酶、心肌钙蛋白、草酰乙酸转氨酶、乳酸脱氢酶、α-羟丁酸和C反应蛋白显著低于危重症组(P ＜ 0.05);重症组第3代小儿死亡危险评分(PRISM Ш)低于危重症组(P ＜ 0.05),小儿危重病例评分(PCIS)高于危重症组(P ＜ 0.05).结论 儿童甲型H1N1流感危重症相对于重症,发病年龄较大,受损器官较多,早期氧合指数、肌酸激酶、影像学检查及PRISM Ⅲ、PCIS评分有助于对病情危重程度尽早作出判断.有缺铁性贫血、脑性瘫痪和先天性心脏病等基础疾病的患儿易发展成为危重症.在选择抗生素时要考虑到重症和危重症患儿混合感染细菌谱的异同.%Objective To explore the different clinical characteristics and risk factors between severely and critically iii children with novel H1N1 influenza for the guidance of the prophylaxis and therapy clinically. Methods Seventy-six eases with novel H1N1 influenza admitted during Oct. 1 to Dec.15, 2009 were divided into the severe group (n＝60) and the critical group (n＝16) according to the third edition guideline established by the Ministry of Health, and the clinical features were compared between two groups. Results The average age of severe cases (2.91 ±2.26 y) was significantly younger than that of critical cases (4.68 ± 4.35 y) (P < 0.05), and the mean length of hospital stay in the severe cases (7.75 ± 3.06 d) was significantly shorter Iran that in the critical cases (19.6 ± 7.72 d)(P < 0.05). The common pathogens of the mixed bacterial infection were Streptococcus pneumoniae in the severe cases and Staphylococcus aureus in the critical cases, respectively. There were 31.6％ of the severe cases and 56.3％ of the critical cases to have the coexistenee of the underlying disease (P < 0.05). The most common underlying diseases were asthraa and iron deficiency anemia in the severe cases, and iron deficiency anemia, cerebral palsy and congenital heart disease in the critical cases, respectively. The oxygenation index (PaO2/FiO2) in the severe cases (307.18 ± 55.73)was significantly higher compared to that in the critical cases (187.50 ± 73.62) (P 〈 0.05). The levels of the serum prealbumin (PA) and albumin (A) were significantly higher in the severe cases than those in the critical cases, while the levels of the creatine kinasc (CK), cardiac troponins I (cTnI), aspartate aminotransferasc (AST), lactate dehydrogenase (LDH), α-hydroxybutyric acid (α-HBDH) and C-reactive protein (CRP) in the severe cases were significantly lower than those in the critical cases (P〈 0.05 for all). The severe eases had lower score of admission Pediatrie Risk of Mortality Ⅲ (PRISM Ⅲ ) and higher Pediatries Critical Illness Score (PCIS) compared to critical eases (P〈 0.05).Conclusions The critical cases with novel H1N1 influenza are commonly older than the severe cases, and usually with more organs injuried. It will be helpful to undertake the lahoratory tests (such as PaO2/FiO2 and CK, etc.), imaging examination,PRISM Ⅲ score and PCIS seore for the evaluation of the disease severity and prognosis. More attention ought to be paid to the children with iron deficiency anemia, cerebral palsy or congenital heart disease in order to prevent their conversion from severe cases to critical cases. The choice of antibiotics shall be made based on the difference in the bacterial spectrum of the nfixed infection between the severe and critical cases.
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