脊柱术后伤口感染PPT参考幻灯片

1、脊柱术后伤口感染原因及治疗策略,北京大学第三医院骨科 田耘,1,2020/9/2,Surgical Site Infection (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,Because the medical,economic and social costs of SSI are enormous， any significant reduction in risks will pay dividends,2,2020/9/2,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,3,2020/9/2,Surgical Site Inf

2、ection (SSI),SSI was defined as: any postoperative wound that required treatment with oral or intravenous antibiotics or surgical debridement 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 Albert F. Pull ter Gunne C. J. H. M. van Laarhoven David B. Cohen Incidence of surgical site infection following adult spinal

3、 deformity surgery: an analysis of patient risk Eur Spine J (2010) 19:982988,4,2020/9/2,SSI的定义,手术区出现渗出，可培养出一种或多种致病菌 A wound infection was defined as presence of purulence at the operative site and a microbiologic culture positive for one or more organisms JENNIFERB . MASSIE B, S Postoperative Poster

4、ior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99-108,5,2020/9/2,Surgical site infections (SSI) CDC criteria (Centres for Disease Control and prevention),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。 An infection was considered to be a surgical site infection when it occured

5、at the site of the surgery within 30 days after the operation or within 1 year if the operation included placement of a foreign body, e.g. an implant. J. J. P. Schimmel P. P. Horsting M. de Kleuver G. Wonders J. van Limbeek Risk factors for deep surgical site infections after spinal fusion Eur Spine

6、 J (2010) 19:17111719,6,2020/9/2,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；43：229-231 1.61%（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；21：453-456,7,2020/9/2,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0.712%。 46/830 (5.0%),

7、 Albert F. Pull ter Gunne C. J. H. M. van Laarhoven David B. Cohen Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk Eur Spine J (2010) 19:982988 36/1,568（ 2.2%） J. J. P. Schimmel P. P. Horsting M. de Kleuver G. Wonders J. van Limbeek Risk fac

8、tors for deep surgical site infections after spinal fusion Eur Spine J (2010) 19:17111719,8,2020/9/2,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,9,2020/9/2,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,10,2020/9/2,危险因素,Obesity (P = 0.035) and history of prior SSI (P = 0.045) significantly increased the ris

9、k of SSI Albert F. Pull ter Gunne C. J. H. M. van Laarhoven David B. Cohen Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk Eur Spine J (2010) 19:982988,11,2020/9/2,危险因素,吸烟史 smoking showed a significant difference between the groups 肥胖 A near

10、ly significant difference was found in the categorized BMI 多节段固定 in the infected group a larger portion of surgeries involved four or more levels (42%), J. J. P. Schimmel P. P. Horsting M. de Kleuver G. Wonders J. van Limbeek Risk factors for deep surgical site infections after spinal fusion Eur Spi

11、ne J (2010) 19:17111719,12,2020/9/2,危险因素,糖尿病 In the final model diabetes had the strongest association with SSI 既往手术史 a positive history of previous spinal surgery had a strong association with the occurrence of an infection, with an odds ratio of 3.70 J. J. P. Schimmel P. P. Horsting M. de Kleuver

12、G. Wonders J. van Limbeek Risk factors for deep surgical site infections after spinal fusion Eur Spine J (2010) 19:17111719,13,2020/9/2,危险因素-手术时间,an increased operating time will result in significant increased risk for SSI Pull ter Gunne AF, Cohen DB (2009) Incidence, prevalence and analysis of ris

13、k factors for surgical site infection following adult spinal surgery. Spine (in press）,14,2020/9/2,危险因素-手术时间,Surgical literature documents that operations lasting longer than 5 hours have increased wound-infection rates Johnston, D. H., Fairclough, J. A, and Brown. E. M.: Microbial surveillance in t

14、he surgical intensive care unit. Surg. Gynecol. Obstet. I39:32 1, 1974,15,2020/9/2,SSI 的症状,present with at least one of the classical signs of inflammation (pain, swelling, redness, increased local temperature) drainage of purulent fluid from the operating incision, spontaneous wound dehiscention or

15、 an abces or other signs of infection at observation, re-operation, histo-pathological or radiological investigation,16,2020/9/2,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., and Pappas, A. M.: Infections after spinal fusion using internal fixation instrumentation. Orthop. Clin. North Am. 3:9

16、9, 1972,17,2020/9/2,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., and Pappas, A. M.: Infections after spinal fusion using internal fixation instrumentation. Orthop. Clin. North Am. 3:99, 1972,18,2020/9/2,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

17、状态改变，新出现的神经病损,19,2020/9/2,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. de Kleuver G. Wonders J. van Limbeek Risk factors for deep surgical site infections after spinal fusion Eur Spine J (2010) 19:17111719,20,2020/9/2,致病菌,The most common organism cultured was Staphy

18、lococcus aureus 金黄色葡萄球菌 High-risk patients should be informed about the increased risk of complications,21,2020/9/2,细菌学,46 patients had single organisms isolated and 28 patients had polymicrobial infections. 丙酸杆菌 34 金葡 32 表皮葡萄球菌 18 Iona Collins The diagnosis and management of infection following ins

19、trumented spinal fusion. Eur Spine J (2008) 17:445450,22,2020/9/2,Micro-organism(s) Number of cases 金葡 27 E. colib 1 Proteus mirabilis 1 CNSAc 2 Streptococcus 1 Enterococcus 1 CNSAc ? S. aureusa 1 Enterobacter ? S. aureusa 1 Enterococcus ? S. aureusa 1,23,2020/9/2,Gram Positive,金黄色葡萄球菌 12 表皮葡萄球菌8 En

20、ierococcirs . faecalis 2 Strepiococciis viridans 1 Diphtheroids I Propionihacteriiitn ucnes 1 Peptococcus species (anaerobe) 3 species (anaerohe) I,Gram Negative,阴沟场杆菌 4 Serratis murcescens I Pseudomonas aeriiginosa 1 Pseiidotnonas maltophilia 1 Acinetobacler anilratiis I Bucteroides species (anaero

21、be) 3 Closirodium dijicile (anaerobe) I 12* Peptostreptococcirs,24,2020/9/2,伤口感染的预防,25,2020/9/2,Center of Disease Control (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,26,2020/9/2,Several preventive (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,27,2020/9/2,病菌的来源,病菌有可能来源于医生；亦有可能来源于患者。 Crowding and exces

22、sive movement in the operating room add still further risk of airborne contamination,28,2020/9/2,外科医生,Double gloving and periodic routine outer glove changes should be considered in lengthy cases,29,2020/9/2,患者,术前洗澡 会阴冲洗,30,2020/9/2,Locally traumatized areas should be allowed to heal before an incis

23、ion is made JENNIFERB . MASSIE B, S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99-108,31,2020/9/2,抗生素,The role of prophylactic antibiotics in spinal surgery is well established 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., and Cur

24、tin, J. A,: Prophylactic antibiotics and wound infections following laminectomy for lumbar disc herniation-a retrospective study. J. Neurosurg. 43:727. 1975.,32,2020/9/2,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,33,2020/9/2,术中伤口冲洗,a solution of povidoneiodine (PVPI) and hydrogen peroxide (H2O2). red

25、ucing the rate of post-operative infection in spine surgery. 7/460 to 0/490 Simone Ulivieri Prevention of post-operative infections in spine surgery by wound irrigation with a solution of povidoneiodine and hydrogen peroxide Arch Orthop Trauma Surg 2011 ChengMT, ChangMC,Wang ST,YuWK, LiuCL, ChenTH(2

26、005) Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine 30:16891693,34,2020/9/2,35,2020/9/2,治疗,怀疑伤口感染需要及时、积极、手术treatment of the suspected infection should be prompt, aggressive, and surgical 抗生素需要及时应用Antibiotic treatment is usually a

27、djunctive and follows definitive surgical debridement,36,2020/9/2,Oxford Skeletal InfectionResearch and Intervention Service (OSIRIS),eight tissue samples taken from areas immediately adjacent to the instrumentation, along the length of the wound Six samples were sent for microbiology culture and mi

28、croscopy and two were immediately fixed in formalin and sent for histological examination 发现感染 术中标本的采取,37,2020/9/2,脊柱术后感染,38,2020/9/2,早期外科手术包括切开、冲洗、清创术early surgical intervention with incision, irrigation, and debridement 特别是存在金属内固定、骨移植、硬膜暴露情况particularly in the presence of metallic implants, bone g

29、raft, and exposed dura, appear to exceed the risks of delay,39,2020/9/2,40,2020/9/2,41,2020/9/2,Michael T. Rohmiller, Closed Suction Irrigation for the Treatment of Postoperative Wound Infections Following Posterior Spinal Fusion and Instrumentation SPINE Volume 35, Number 6, pp 642646,42,2020/9/2,C

30、losed suction irrigationsystem,43,2020/9/2,44,2020/9/2,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 Deep wound infections were closed over inflow-outflow tubes to allow continuous irrigation with fluid， 5-10 days,45,2020/9/2,真空负压吸引,Ludwig Labler ,Marius Keel ,Otmar Trentz Michael

31、Heinzelmann Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery Eur Spine J (2006) 15:13881396,46,2020/9/2,真空负压吸引,47,2020/9/2,真空负压吸引,V.A.C.TM dressing was changed after 3 days in anaverage (range: 17 days) only during repeated second look ope

32、rations and performed 3.8 times in an average 14/15 治愈率,48,2020/9/2,内固定保留与否,28 / 33 cases with spinal implants (85%) it was possible to leave the implants in situ and obtain healing of the infection JENNIFERB . MASSIE B, S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Rel

33、ated Research 1992；284：99-108,49,2020/9/2,内固定的命运,at the time of diagnosis of infection. If unfused, each patient was given 6 weeks of intravenous antibiotics, then oral antibiotics until fusion was complete and the implants were then removed In the fused spine, the management depended on the nature

34、of the pathogen. Iona Collins The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J (2008) 17:445450,50,2020/9/2,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,51,2020/9/2,迟发感染内固定命运,迟发感染时间 2.91.7(range 0.58.0) years after the initial procedure

35、 发生率45/937(5%) late infections Instrumentation removal and primary wound closure are reliably curative Michael Muschik Implant removal for late-developing infection after instrumented posterior spinal fusion for scoliosis: reinstrumentation reduces loss of correction. A retrospective analysis of 45 cases Eur Spine J (2004) 13 : 645651,52,2020/9/2,植骨的命运