脊柱术后伤口感染ppt课件.ppt

脊柱术后伤口感染原因及治疗策略 SurgicalSiteInfection SSI SSI意味着医生的痛苦 患者的眼泪高病残率 成倍增加的花费 Becausethemedical economicandsocialcostsofSSIareenormous anysignificantreductioninriskswillpaydividends 内容摘要 定义流行病学影响因素病原学预防治疗措施需要关注的问题 SurgicalSiteInfection SSI SSIwasdefinedas anypostoperativewoundthatrequiredtreatmentwithoralorintravenousantibioticsorsurgicaldebridement任何术后伤口需要进行口服或静脉使用抗生素 或者需要外科手术清理者AlbertF PullterGunne C J H M vanLaarhoven DavidB CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery ananalysisofpatientriskEurSpineJ 2010 19 982 988 SSI的定义 手术区出现渗出 可培养出一种或多种致病菌AwoundinfectionwasdefinedaspresenceofpurulenceattheoperativesiteandamicrobiologicculturepositiveforoneormoreorganismsJENNIFERB MASSIEB SPostoperativePosteriorSpinalWoundInfections ClinicalOrthopaedicsandRelatedResearch1992 284 99 108 Surgicalsiteinfections SSI CDCcriteria CentresforDiseaseControlandprevention 手术区域的感染发生于术后30天内 或有内固定的患者术后1年内出现的感染 Aninfectionwasconsideredtobeasurgicalsiteinfectionwhenitoccuredatthesiteofthesurgerywithin30daysaftertheoperationorwithin1yeariftheoperationincludedplacementofaforeignbody e g animplant J J P Schimmel P P Horsting M deKleuver G Wonders J vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ 2010 19 1711 1719 流行病学 无内固定0 41 25 6108 有内固定者感染发生率为1 0 11 1112 总体感染发生率为0 5 36 7220 田耘陈仲强周方刘忠军脊柱术后伤口深部感染的处理中华外科杂志2005 43 229 2311 61 15 924 仉建国李书纲杨新宇田野邱贵兴脊柱侧凸后路矫形融合术术后感染的治疗中华骨科杂志2001 21 453 456 流行病学 手术切口区感染是脊柱手术经常出现的并发症发生率 文献报道0 7 12 46 830 5 0 AlbertF PullterGunne C J H M vanLaarhoven DavidB CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery ananalysisofpatientriskEurSpineJ 2010 19 982 98836 1 568 2 2 J J P Schimmel P P Horsting M deKleuver G Wonders J vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ 2010 19 1711 1719 SSI的危险因素 高龄肥胖糖尿病其他伴随疾病吸烟身体状况差完全的神经功能损伤 SSI的高危因素 手术因素 翻修手术肿瘤手术出血多手术时间长多节段 危险因素 Obesity P 0 035 andhistoryofpriorSSI P 0 045 significantlyincreasedtheriskofSSIAlbertF PullterGunne C J H M vanLaarhoven DavidB CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery ananalysisofpatientriskEurSpineJ 2010 19 982 988 危险因素 吸烟史smokingshowedasignificantdifferencebetweenthegroups肥胖AnearlysignificantdifferencewasfoundinthecategorizedBMI多节段固定intheinfectedgroupalargerportionofsurgeriesinvolvedfourormorelevels 42 J J P Schimmel P P Horsting M deKleuver G Wonders J vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ 2010 19 1711 1719 危险因素 糖尿病InthefinalmodeldiabeteshadthestrongestassociationwithSSI既往手术史apositivehistoryofpreviousspinalsurgeryhadastrongassociationwiththeoccurrenceofaninfection withanoddsratioof3 70J J P Schimmel P P Horsting M deKleuver G Wonders J vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ 2010 19 1711 1719 危险因素 手术时间 anincreasedoperatingtimewillresultinsignificantincreasedriskforSSIPullterGunneAF CohenDB 2009 Incidence prevalenceandanalysisofriskfactorsforsurgicalsiteinfectionfollowingadultspinalsurgery Spine inpress 危险因素 手术时间 Surgicalliteraturedocumentsthatoperationslastinglongerthan5hourshaveincreasedwound infectionratesJohnston D H Fairclough J A andBrown E M Microbialsurveillanceinthesurgicalintensivecareunit Surg Gynecol Obstet I39 321 1974 SSI的症状 presentwithatleastoneoftheclassicalsignsofinflammation pain swelling redness increasedlocaltemperature drainageofpurulentfluidfromtheoperatingincision spontaneouswounddehiscentionoranabcesorothersignsofinfectionatobservation re operation histo pathologicalorradiologicalinvestigation 感染的诊断 表浅伤口 红肿 压痛 积液渗出GRAM染色和培养ESR增快Keller R B andPappas A M Infectionsafterspinalfusionusinginternalfixationinstrumentation Orthop Clin NorthAm 3 99 1972 深部感染诊断 文献报道术后平均11天的发现期局部早期可能无症状 患者有全身不适的症状 继而伤口痛 发热 寒战等 体检伤口叩痛局部穿刺和细菌GRAM染色确诊 亦有可能阴性WBC及ESR上升Keller R B andPappas A M Infectionsafterspinalfusionusinginternalfixationinstrumentation Orthop Clin NorthAm 3 99 1972 影像学的帮助临床症状体征很重要 严重的伤口疼痛 头痛 精神状态改变 新出现的神经病损 感染诊断时间 36 1 568 2 2 早期13 5天 10 21天 迟发4例J J P Schimmel P P Horsting M deKleuver G Wonders J vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ 2010 19 1711 1719 致病菌 ThemostcommonorganismculturedwasStaphylococcusaureus金黄色葡萄球菌High riskpatientsshouldbeinformedabouttheincreasedriskofcomplications 细菌学 46patientshadsingleorganismsisolatedand28patientshadpolymicrobialinfections 丙酸杆菌34金葡32表皮葡萄球菌18IonaCollinsThediagnosisandmanagementofinfectionfollowinginstrumentedspinalfusion EurSpineJ 2008 17 445 450 Micro organism s Numberofcases金葡27E colib1Proteusmirabilis1CNSAc2Streptococcus1Enterococcus1CNSAc S aureusa1Enterobacter S aureusa1Enterococcus S aureusa1 GramPositive 金黄色葡萄球菌12表皮葡萄球菌8Enierococcirs faecalis2Strepiococciisviridans1DiphtheroidsIPropionihacteriiitnucnes1Peptococcusspecies anaerobe 3species anaerohe I GramNegative 阴沟场杆菌4SerratismurcescensIPseudomonasaeriiginosa1Pseiidotnonasmaltophilia1AcinetobacleranilratiisIBucteroidesspecies anaerobe 3Closirodiumdijicile anaerobe I12 Peptostreptococcirs 伤口感染的预防 CenterofDiseaseControl CDC Guidelines 手术室通风消毒方法术者手和前臂的消毒术前应用抗生素 Severalpreventive medical measures 既往有脊柱手术的患者术后抗生素最少应用3天禁烟 病菌的来源 病菌有可能来源于医生 亦有可能来源于患者 Crowdingandexcessivemovementintheoperatingroomaddstillfurtherriskofairbornecontamination 外科医生 Doubleglovingandperiodicroutineouterglovechangesshouldbeconsideredinlengthycases 患者 术前洗澡会阴冲洗 LocallytraumatizedareasshouldbeallowedtohealbeforeanincisionismadeJENNIFERB MASSIEB SPostoperativePosteriorSpinalWoundInfections ClinicalOrthopaedicsandRelatedResearch1992 284 99 108 抗生素 Theroleofprophylacticantibioticsinspinalsurgeryiswellestablished术前即刻应用抗生素术后应用多长时间 决定于患者体质 手术时间 术中出血 固定节段等Honvit7 N H andCurtin J A Prophylacticantibioticsandwoundinfectionsfollowinglaminectomyforlumbardischerniation aretrospectivestudy J Neurosurg 43 727 1975 抗生素的选择 个体化二代头孢是经济的选择如术前合并其他系统感染 应根据培养结果 术中伤口冲洗 asolutionofpovidone iodine PVP I andhydrogenperoxide H2O2 reducingtherateofpost operativeinfectioninspinesurgery 7 460to0 490SimoneUlivieriPreventionofpost operativeinfectionsinspinesurgerybywoundirrigationwithasolutionofpovidone iodineandhydrogenperoxideArchOrthopTraumaSurg2011ChengMT ChangMC WangST YuWK LiuCL ChenTH 2005 Efficacyofdilutebetadinesolutionirrigationinthepreventionofpostoperativeinfectionofspinalsurgery Spine30 1689 1693 治疗 怀疑伤口感染需要及时 积极 手术treatmentofthesuspectedinfectionshouldbeprompt aggressive andsurgical抗生素需要及时应用Antibiotictreatmentisusuallyadjunctiveandfollowsdefinitivesurgicaldebridement OxfordSkeletalInfectionResearchandInterventionService OSIRIS eighttissuesamplestakenfromareasimmediatelyadjacenttotheinstrumentation alongthelengthofthewoundSixsamplesweresentformicrobiologycultureandmicroscopyandtwowereimmediatelyfixedinformalinandsentforhistologicalexamination发现感染术中标本的采取 脊柱术后感染 早期外科手术包括切开 冲洗 清创术earlysurgicalinterventionwithincision irrigation anddebridement特别是存在金属内固定 骨移植 硬膜暴露情况particularlyinthepresenceofmetallicimplants bonegraft andexposeddura appeartoexceedtherisksofdelay MichaelT Rohmiller ClosedSuctionIrrigationfortheTreatmentofPostoperativeWoundInfectionsFollowingPosteriorSpinalFusionandInstrumentationSPINEVolume35 Number6 pp642 646 Closedsuctionirrigationsystem 拔出引流的标准 引流 负压还是冲洗引流 保留时间 文献报道5天即可 我们的观点 闭合冲洗引流 7 10天 伤口引流液培养阴性Deepwoundinfectionswereclosedoverinflow outflowtubestoallowcontinuousirrigationwithfluid 5 10days 真空负压吸引 LudwigLabler MariusKeel OtmarTrentzMichaelHeinzelmannWoundconditioningbyvacuumassistedclosure V A C inpostoperativeinfectionsafterdorsalspinesurgeryEurSpineJ 2006 15 1388 1396 真空负压吸引 真空负压吸引 V A C TMdressingwaschangedafter3daysinanaverage range 1 7days onlyduringrepeatedsecondlookoperationsandperformed3 8timesinanaverage14 15治愈率 内固定保留与否 28 33caseswithspinalimplants 85 itwaspossibletoleavetheimplantsinsituandobtainhealingoftheinfectionJENNIFERB MASSIEB SPostoperativePosteriorSpinalWoundInfections ClinicalOrthopaedicsandRelatedResearch1992 284 99 108 内固定的命运 atthetimeofdiagnosisofinfection Ifunfused eachpatientwasgiven6weeksofintravenousantibiotics thenoralantibioticsuntilfusionwascompleteandtheimplantswerethenremovedInthefusedspine themanagementdependedonthenatureofthepathogen IonaCollinsThediagnosisandmanagementofinfectionfollowinginstrumentedspinalfusion EurSpineJ 2008 17 445 450 内固定的命运 内固定是否取出 文献有争论 多数认为可保留 三院观点 早期 3周内 发现的感染应该保留内固定 迟发感染内固定保留困难 迟发感染内固定命运 迟发感染时间2 9 1 7 range0 5 8 0 yearsaftertheinitialprocedure发生率45 937 5 lateinfectionsInstrumentationremovalandprimarywoundclosurearereliablycurativeMichaelMuschikImplantremovalforlate developinginfectionafterinstrumentedposteriorspinalfusionforscoliosis reinstrumentationreduceslossofcorrection Aretrospectiveanalysisof45casesEurSpineJ 2004 13 645 651 植骨的命运 植骨是否取出 文献有相关争论 我们认为后外侧植骨应取出 因