外科手术部位感染的可控性因素-课件

1、外科手术部位感染的可控性因素 外科手术部位感染的可控性因素 目前差不多明确,骨科手术部位的感染包括多方面的风险因素,如各种不同的人群、合并症、手术以及术后相关的因素等 目前差不多明确,骨科手术部位的感染包括多方面的风险因素,如各The patient as a host is an important risk factor for infection, and many, if not most, patients are in suboptimal health、 The patient as a host is an im患者作为宿主本身就是感染最重要的风险因素,即使不是大多数,那也有特

2、别多患者的健康状况并不理想。 患者作为宿主本身就是感染最重要的风险因素,即使不是大多数,那Optimizing the patients medical condition before surgery and eliminating or even diminishing modifiable risk factors for infection (Fig、 1) should lower the risk of surgical site infection、 Optimizing the patients medic在手术前将患者的内科情况调整到最佳状态,杜绝或减少感染的可控性风险因素(

3、图1)应该能够降低手术部位感染的风险。 在手术前将患者的内科情况调整到最佳状态,杜绝或减少感染的可控外科手术部位感染的可控性因素-课件外科手术部位感染的可控性因素-课件Direct scientific evidence showing that modification of these risk factors will lead to a decrease in surgical site infection is not readily available, and much work in this field remains to be done、Direct scientific

4、 evidence sho然而,关于控制这些风险因素便可减少手术部位感染的观点,要找到直截了当的科学证据事实上并不简单,在这一领域仍有特别多工作有待进一步深入。 然而,关于控制这些风险因素便可减少手术部位感染的观点,要找到It is imperative that surgeons have an extensive knowledge of modifiable risk factors affecting the wound-healing process and subsequent wound plications、 It is imperative that surgeons特别必要

5、的是,外科医生应该对影响创口愈合过程以及继发创口并发症的可控性风险因素有一个广泛的认识。特别必要的是,外科医生应该对影响创口愈合过程以及继发创口并发Modifiable Risk Factors for Surgical Site Infection and Possible Preoperative Interventions手术部位感染的可控性风险因素及估计的术前干预措施Modifiable Risk Factors for SuRheumatoid ArthritisPatients with rheumatoid arthritis have an increased risk of

6、infection following orthopaedic procedures、 Patients with rheumatoid arthritis who undergo total joint arthroplasty have a two to three times greater risk of acquiring a postoperative surgical site infection than do patients with osteoarthritis、 Rheumatoid ArthritisPatients 类风湿性关节炎患有类风湿性关节炎的患者骨科手术后感

7、染的风险明显增加。类风湿性关节炎类风湿性关节患者行全关节置换术后发生手术部位感染的风险是骨关节炎患者的2-3倍。类风湿性关节炎患有类风湿性关节炎的患者骨科手术后感染的风险Patients with rheumatoid arthritis are frequently being treated with plex drug regimens that include nonsteroidal anti-inflammatory drugs, corticosteroids, methotrexate, and biologics, all of which have an effect on

8、 wound-healing and the risk of infection、Patients with rheumatoid arthr类风湿性关节炎的患者常常要服用多种药物,包括非甾体类抗炎药、皮质类固醇、氨甲喋呤及生物制剂等,所有这些都会对创口愈合以及感染的风险产生影响。类风湿性关节炎的患者常常要服用多种药物,包括非甾体类抗炎药、There are insufficient data from patients who have undergone orthopaedic procedures to make evidence-based remendations about the

9、 majority of these medications、 There are insufficient data fr目前关于大多数该类药物而言,来自骨科手术患者的数据并尚不足以给出明确的循证医学建议。外科手术部位感染的可控性因素-课件A good working relationship with the patients rheumatologist is critical to making decisions about these medications、A good working relationship wi应注意与患者的风湿科医生保持紧密的联系,以决定这些药物的应用方案

10、。应注意与患者的风湿科医生保持紧密的联系,以决定这些药物的应用Synthesis of the available data suggests the following、 综合现有的数据可得出以下建议Synthesis of the available datNonsteroidal Anti-Inflammatory Drugs非甾体类抗炎药Nonsteroidal Anti-InflammatoryWhile nonsteroidal anti-inflammatory drugs do not seem to increase transfusion requirements, mor

11、bidity, and mortality directly, they may increase intraoperative and postoperative bleeding、Increased bleeding may lead to a postoperative infection、While nonsteroidal anti-inflam尽管非甾体类抗炎药好像并可不能直截了当增加输血的需求、致残率及致死率,但这些药物估计会增加术中和术后的出血量。出血增加估计导致术后感染。尽管非甾体类抗炎药好像并可不能直截了当增加输血的需求、致残率Use of medications with

12、 short half-lives (ibuprofen and indomethacin) should be discontinued one to two days before surgery、 Use of drugs with longer half-lives (naproxen) should be discontinued three days before surgery、 Aspirin use should be discontinued seven to ten days before surgery to allow regeneration of unaffect

13、ed platelets、 Use of medications with short 半衰期较短的药物(布洛芬和吲哚美辛)应在术前1-2天停药,半衰期较长的药物(萘普生)应在术前3天停药,而阿斯匹林应在术前7-10天停药,以便让未受影响的血小板再生。半衰期较短的药物(布洛芬和吲哚美辛)应在术前1-2天停药, While cyclooxygenase-2 (COX-2)-specific nonsteroidal anti-inflammatory drugs may not be associated with as much bleeding as non-COX-2-specific n

14、onsteroidal anti-inflammatory drugs, bone healing may be affected by the latter、 As such, the data are controversial with regard to the best way to handle these newer drugs、 While cyclooxygenase-2 (COX-2尽管环氧化酶-2(COX-2)特异性抑制的非甾体类抗炎药估计并不像非COX-2特异性抑制的非甾体类抗炎药那样与出血量紧密相关,还估计会影响骨愈合,但关于应用这些新药的最佳方案,相关的数据仍然存在

15、争议。尽管环氧化酶-2(COX-2)特异性抑制的非甾体类抗炎药估计Corticosteroids皮质类固醇Inadequate doses of corticosteroids lead to disease flares and, in rare instances, adrenal insufficiency、 Corticosteroids have been shown to increase infection rates and affect wound-healing、 In general, all patients on chronic corticosteroid ther

16、apy should receive their regular dose of corticosteroids perioperatively、 Corticosteroids皮质类固醇Inadequa皮质类固醇的剂量应用不合理可导致疾病发作,同时在一些较为少见的情况下,还估计出现肾上腺功能不全。有研究显示皮质类固醇会增加感染率,影响创口愈合。通常情况下,所有长期接受皮质类固醇治疗的患者在围手术期仍应该依照标准剂量服用皮质类固醇。皮质类固醇的剂量应用不合理可导致疾病发作,同时在一些较为少见The use of stress dose steroids remains controversia

17、l, and guidelines are difficult to establish、 Stress dose steroids should probably not be routinely prescribed but should be individualized on the basis of the length of time for which steroid treatment has been utilized, the anticipated stress level of the surgery, and the presence of other risk fa

18、ctors for infection、 The use of stress dose steroid应用大剂量的类固醇目前仍有争议,指南也特别难确立。大剂量类固醇不应该作为常规来应用,但应该依照应用某种类固醇的持续时间,能够预见的手术相关的应激水平,以及存在感染的其他风险因素等情况,进行个体化的处理。应用大剂量的类固醇目前仍有争议,指南也特别难确立。Methotrexate甲氨蝶呤Most studies on the use of methotrexate perioperatively have not shown an increased risk of infection、 In g

19、eneral, use of methotrexate should not be discontinued perioperatively、 Methotrexate甲氨蝶呤Most studies 特别多研究都显示,术前应用甲氨蝶呤并可不能增加感染的风险。通常情况下,术前不停用甲氨蝶呤。 特别多研究都显示,术前应用甲氨蝶呤并可不能增加感染的风险。Patients with renal insufficiency (preoperatively or postoperatively), poorly controlled diabetes, lung or liver disease, or

20、 a history of alcohol abuse should discontinue using methotrexate preoperatively、 This remendation is especially important for patients undergoing high-stress procedures such as an arthroplasty or tumor resection、 Patients with renal insufficie如患者伴有肾功能不全(术前或术后),糖尿病控制不佳,肺或肝脏疾病,或者酗酒都应该在术前停用甲氨蝶呤。如患者需要进

21、行应激较大的手术,比如关节置换或肿瘤切除手术等,这一建议则尤为重要。如患者伴有肾功能不全(术前或术后),糖尿病控制不佳,肺或肝脏Other Disease-Modifying Antirheumatic Drugs其他缓解病情的抗风湿类药物Very little data are available to enable one to make remendations about these medications。 Consultation with a rheumatologist preoperatively is highly remended、 Other Disease-Modif

22、ying Antirh关于这一类药物,几乎没有相关的数据可供参考。对此,在术前请风湿科医生会诊则是特别明智的。关于这一类药物,几乎没有相关的数据可供参考。Biologics: Tumor-Necrosis-Factor (TNF) Antagonists and Interleukin-1 (IL-1) Antagonists生物制剂:肿瘤坏死因子(TNF)拮抗剂和白细胞介素-1(IL-1)拮抗剂Biologics: Tumor-Necrosis-FactThere are minimal data and experience on which to base strict remendat

23、ions about either of these classes of drugs、 Serious infection is a known plication of TNF-inhibitor therapy、 Perioperative use of such therapy has been shown to be safe in foot and ankle surgery、 There are minimal data and exp对以上两类药物,目前相关的数据和经验都极为有限、严重的感染是TNF拮抗剂治疗的一个重要的并发症。有研究证明,在足踝外科手术的围手术期应用这些药物是

24、安全的。 对以上两类药物,目前相关的数据和经验都极为有限、At this time, a conservative approach should be taken、 For patients undergoing intensive procedures in particular, these medications should be withheld preoperatively for at least one dosing cycle and postoperatively until adequate wound-healing is observed、 At this time

25、, a conservative a此时,采取保守一些的方法依然比较可取的。尤其关于手术较大的患者,这些药物应在术前停用至少一个疗程,并在术后创口愈合后再考虑续用。此时,采取保守一些的方法依然比较可取的。Human Immunodeficiency Virus (HIV)人类免疫缺陷病毒(HIV)The increased longevity of HIV-positive patients has created a new subset of potential candidates for total joint replacements and other orthopaedic pr

26、ocedures、 Several retrospective reports, most involving small numbers of patients, have provided mixed results、 Human Immunodeficiency Virus (随着HIV阳性患者的寿命不断延长,在适合做全关节置换和其他骨科手术的患者人群中也增加了如此一个亚组。有几项回顾性的病例报告,大多样本量都较小,相关的结果差别也特别大。随着HIV阳性患者的寿命不断延长,在适合做全关节置换和其他骨 Whereas some studies showed an alarming rate

27、 of postoperative infection in these patients, other studies did not、 Prospective randomized studies on this topic are lacking、 Whereas some studies showed a有的研究显示这些患者术后出现高的惊人的感染率,而另外一些研究的结果则并非如此。对这一问题目前尚缺乏前瞻性的随机研究。有的研究显示这些患者术后出现高的惊人的感染率,而另外一些研究Diabetes Mellitus and Hyperglycemia糖尿病和高血糖Diabetes has

28、been associated with an increased risk of surgical site infection in several orthopaedic areas、 While this diabetic disadvantage may be due, in part, to the impact of the pathologic changes resulting from the diabetes, it is more likely that the acute effects of perioperative hyperglycemia are even

29、more detrimental、Diabetes Mellitus and Hypergly在骨科的多个领域中,糖尿病都会增加手术部位感染的风险。尽管,从某种程度上说,“糖尿病的不利之处”估计与糖尿病所引起的病理改变有关,然而,围手术期急性的高血糖效应则估计更为不利在骨科的多个领域中,糖尿病都会增加手术部位感染的风险。The increased risk of infection in diabetics undergoing orthopaedic surgery is often associated with plications related to wound-healing 、

30、To achieve appropriate wound-healing in diabetic patients, their nutritional status and insulin regimen must be optimized before they undergo any surgical procedure、 The increased risk of infectio进行骨科手术的糖尿病患者感染的风险较高,这通常与创口愈合相关的并发症有关(图2)。为了使糖尿病患者的创口能顺利愈合,在进行任何手术之前,应该使其营养状况和胰岛素的用法都调整到最佳的状态。进行骨科手术的糖尿病患

31、者感染的风险较高,这通常与创口愈合相关Fig、 2 Infected wound dehiscence in a sixty-three-year-old woman with poorly controlled insulin-dependent diabetes who underwent a total knee replacement、图2 女性,63岁,行全膝关节置换术,胰岛素依赖型糖尿病控制不佳,创口感染开裂。外科手术部位感染的可控性因素-课件A recent study evaluating surgical site infection following orthopaedi

32、c spinal surgery identified hyperglycemia in patients not previously diagnosed with diabetes as a potential risk factor。A recent study evaluating surg最近有一项评价骨科脊柱手术后的手术部位感染的研究,将既往未曾诊断为糖尿病的患者而出现高血糖视为一个潜在的危险因素。 最近有一项评价骨科脊柱手术后的手术部位感染的研究,将既往未曾MalnutritionMalnutrition is a known risk factor for deep infec

33、tion after a variety of orthopaedic surgical procedures、Patients at risk for malnutrition, such as the elderly and those who have gastrointestinal diseases, renal failure, alcoholism, cancer, or any chronic disease, should have their nutritional status checked preoperatively、MalnutritionMalnutrition

34、 is a营养不良大伙儿明白,营养不良关于各种骨科手术的深部感染都是一个风险因素。有些患者通常伴有营养不良的相关风险,如患有胃肠道疾病、肾功能不全、酗酒、癌症或其他慢性病的老年患者。因此,术前应该对这些患者的营养状况进行认确实检查营养不良大伙儿明白,营养不良关于各种骨科手术的深部感染都是A total lymphocyte count of 1500/mm3(1、5109/L), a serum albumin level of3、5 g/dL, or a transferrin level of 226mg/Dl has been associated with an increased r

35、ate of wound plications、A total lymphocyte count of 1有研究显示,淋巴细胞总数1500/mm3(1、5109/L),血清白蛋白水平3、5g/dL,或转铁蛋白水平226mg/dL会增加创口并发症的发生率有研究显示,淋巴细胞总数103/mL on urine culturesome remendations、a urinalysis我们结合相关文献,提出以下的一些建议:做尿液分析和尿培养。如有以下情况,应该考虑推迟手术,高风险患者尤其如此:术前评估显示有尿道梗阻的相关症状。患者有排尿困难和尿频等症状,同时尿培养显示尿菌落计数103/mL。我们结合

36、相关文献,提出以下的一些建议:Preoperative AnemiaSome reports have indicated that post-operative anemia treated with allogenic blood transfusion is a risk factor for surgical site infection、Several studies have shown that, when preoperative anemia is corrected, the risk of postoperative allogenic blood transfusion

37、s is diminished、 Preoperative AnemiaSome report术前贫血有研究报告指出,同种异体输血来治疗术后贫血是手术部位感染的风险因素之一。有几项研究显示,当术前贫血纠正后,术后外源性输血的风险便可大大减少 术前贫血有研究报告指出,同种异体输血来治疗术后贫血是手术部Screening for preoperative anemia and correcting the condition through the use of rebinant human erythropoietin (epoetin alfa) therapy has been studie

38、d in orthopaedic patients and has proven to be beneficial in some but not all instances、 Epoetin alfa directly increases preoperative red-blood-cell mass, hemoglobin concentration, and hematocrit levels、 Even when a patient has chosen to donate autologous blood preoperatively, erythropoietin may be

39、used as an adjunct。Screening for preoperative ane对术前贫血进行筛查,并通过应用重组人红细胞生成素(epoetin alfa,阿法依泊汀)进行治疗以纠正这种状况,这一方法已有学者在骨科患者中进行过研究,结果证明,对有些病例但并不是所有病例都有效。阿法依泊汀可直截了当增加术前血红细胞总量、血红蛋白浓度和红细胞压积水平。即便对选择术前留取自体血的患者,也可辅助性地应用促红细胞生成素。 对术前贫血进行筛查,并通过应用重组人红细胞生成素(epoet Lastly, iron deficiency has been shown to be a mon re

40、ason for failure of erythropoietin treatment, so iron levels need to be supplemented while the patient is being treated with rebinant erythropoietin、 Lastly, iron deficiency has b最后,已有研究证实,铁缺乏是导致促红细胞生成素治疗失败的常见原因,因此,对准备应用重组人红细胞生成素进行治疗的患者,有必要适当补充铁剂。最后,已有研究证实,铁缺乏是导致促红细胞生成素治疗失败的常见Local or Remote Orthopaedic Infec