外科手術(shù)部位感染的可控性因素

1、Modifiable Risk Factors for Surgical Site Infection手術(shù)部位感染的可控性風(fēng)險(xiǎn)因素手術(shù)部位感染的可控性風(fēng)險(xiǎn)因素 The Journal of Bone and Joint Surgery (American). 2011;93:398-404. Multiple risk factors for orthopaedic surgical site infection, have been identified： including a wide variety of demographic, comorbidity operative, and

2、postoperative variables, 目前已經(jīng)明確，骨科手術(shù)部位的感染包括多方面的風(fēng)險(xiǎn)因素，如各種不同的人群、合并癥、手術(shù)以及術(shù)后相關(guān)的因素等 The patient as a host is an important risk factor for infection, and many, if not most, patients are in suboptimal health. 患者作為宿主本身就是感染最重要的風(fēng)險(xiǎn)因素，即使不是大多數(shù)，那也有很多患者的健康狀況并不理想。 Optimizing the patients medical condition before sur

3、gery and eliminating or even diminishing modifiable risk factors for infection (Fig. 1) should lower the risk of surgical site infection. 在手術(shù)前將患者的內(nèi)科情況調(diào)整到最佳狀態(tài)，杜絕或減少感染的可控性風(fēng)險(xiǎn)因素（圖1）應(yīng)該可以降低手術(shù)部位感染的風(fēng)險(xiǎn)。 Direct scientific evidence showing that modification of these risk factors will lead to a decrease in surg

4、ical site infection is not readily available, and much work in this field remains to be done. 然而，對(duì)于控制這些風(fēng)險(xiǎn)因素便可減少手術(shù)部位感染的觀(guān)點(diǎn)，要找到直接的科學(xué)證據(jù)其實(shí)并不簡(jiǎn)單，在這一領(lǐng)域仍有很多工作有待進(jìn)一步深入。 It is imperative that surgeons have an extensive knowledge of modifiable risk factors affecting the wound-healing process and subsequent wound

5、 complications. 非常必要的是，外科醫(yī)生應(yīng)該對(duì)影響創(chuàng)口愈合過(guò)程以及繼發(fā)創(chuàng)口并發(fā)癥的可控性風(fēng)險(xiǎn)因素有一個(gè)廣泛的認(rèn)識(shí)。Modifiable Risk Factors for Surgical Site Infection and Possible Preoperative Interventions手術(shù)部位感染的可控性風(fēng)險(xiǎn)因素及可能的術(shù)前干預(yù)措施手術(shù)部位感染的可控性風(fēng)險(xiǎn)因素及可能的術(shù)前干預(yù)措施Rheumatoid Arthritis Patients with rheumatoid arthritis have an increased risk of infection follo

6、wing 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. 類(lèi)風(fēng)濕性關(guān)節(jié)炎 患有類(lèi)風(fēng)濕性關(guān)節(jié)炎的患者骨科手術(shù)后感染的風(fēng)險(xiǎn)明顯增加。 類(lèi)風(fēng)濕性關(guān)節(jié)炎類(lèi)風(fēng)濕性關(guān)節(jié)患者行全關(guān)節(jié)置換術(shù)后發(fā)生手術(shù)部位感染的風(fēng)

7、險(xiǎn)是骨關(guān)節(jié)炎患者的2-3倍。 Patients with rheumatoid arthritis are frequently being treated with complex drug regimens that include nonsteroidal anti-inflammatory drugs, corticosteroids, methotrexate, and biologics, all of which have an effect on wound-healing and the risk of infection. 類(lèi)風(fēng)濕性關(guān)節(jié)炎的患者常常要服用多種藥物，包括非甾體

8、類(lèi)抗炎藥、皮質(zhì)類(lèi)固醇、氨甲喋呤及生物制劑等，所有這些都會(huì)對(duì)創(chuàng)口愈合以及感染的風(fēng)險(xiǎn)產(chǎn)生影響。 There are insufficient data from patients who have undergone orthopaedic procedures to make evidence-based recommendations about the majority of these medications. 目前對(duì)于大多數(shù)該類(lèi)藥物而言，來(lái)自骨科手術(shù)患者的數(shù)據(jù)并尚不足以給出明確的循證醫(yī)學(xué)建議。 A good working relationship with the patients r

9、heumatologist is critical to making decisions about these medications. 應(yīng)注意與患者的風(fēng)濕科醫(yī)生保持密切的聯(lián)系，以決定這些藥物的應(yīng)用方案。 Synthesis of the available data suggests the following. 綜合現(xiàn)有的數(shù)據(jù)可得出以下建議Nonsteroidal Anti-Inflammatory Drugs 非甾體類(lèi)抗炎藥 While nonsteroidal anti-inflammatory drugs do not seem to increase transfusion r

10、equirements, morbidity, and mortality directly, they may increase intraoperative and postoperative bleeding. Increased bleeding may lead to a postoperative infection. 雖然非甾體類(lèi)抗炎藥似乎并不會(huì)直接增加輸血的需求、致殘率及致死率， 但這些藥物可能會(huì)增加術(shù)中和術(shù)后的出血量。 出血增加可能導(dǎo)致術(shù)后感染。 Use of medications with short half-lives (ibuprofen and indometha

11、cin) 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 unaffected platelets. 半衰期較短的藥物（布洛芬和吲哚美辛）應(yīng)在術(shù)前1-2天停藥

12、， 半衰期較長(zhǎng)的藥物（萘普生）應(yīng)在術(shù)前3天停藥， 而阿斯匹林應(yīng)在術(shù)前7-10天停藥， 以便讓未受影響的血小板再生。 While cyclooxygenase-2 (COX-2)-specific nonsteroidal anti-inflammatory drugs may not be associated with as much bleeding as non-COX-2-specific nonsteroidal anti-inflammatory drugs, bone healing may be affected by the latter. As such, the data

13、 are controversial with regard to the best way to handle these newer drugs. 雖然環(huán)氧化酶-2（COX-2）特異性抑制的非甾體類(lèi)抗炎藥可能并不像非COX-2特異性抑制的非甾體類(lèi)抗炎藥那樣與出血量密切相關(guān)， 還可能會(huì)影響骨愈合， 但關(guān)于應(yīng)用這些新藥的最佳方案，相關(guān)的數(shù)據(jù)仍然存在爭(zhēng)議。Corticosteroids皮質(zhì)類(lèi)固醇 Inadequate doses of corticosteroids lead to disease flares and, in rare instances, adrenal insufficie

14、ncy. Corticosteroids have been shown to increase infection rates and affect wound-healing. In general, all patients on chronic corticosteroid therapy should receive their regular dose of corticosteroids perioperatively. 皮質(zhì)類(lèi)固醇的劑量應(yīng)用不合理可導(dǎo)致疾病發(fā)作，并且在一些較為少見(jiàn)的情況下，還可能出現(xiàn)腎上腺功能不全。 有研究顯示皮質(zhì)類(lèi)固醇會(huì)增加感染率，影響創(chuàng)口愈合。 通常情況下，

15、所有長(zhǎng)期接受皮質(zhì)類(lèi)固醇治療的患者在圍手術(shù)期仍應(yīng)該按照標(biāo)準(zhǔn)劑量服用皮質(zhì)類(lèi)固醇。 The use of stress dose steroids remains controversial, 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 be

16、en utilized, the anticipated stress level of the surgery, and the presence of other risk factors for infection. 應(yīng)用大劑量的類(lèi)固醇目前仍有爭(zhēng)議，指南也很難確立。 大劑量類(lèi)固醇不應(yīng)該作為常規(guī)來(lái)應(yīng)用， 但應(yīng)該根據(jù)應(yīng)用某種類(lèi)固醇的持續(xù)時(shí)間，可以預(yù)見(jiàn)的手術(shù)相關(guān)的應(yīng)激水平，以及存在感染的其他風(fēng)險(xiǎn)因素等情況，進(jìn)行個(gè)體化的處理。Methotrexate甲氨蝶呤 Most studies on the use of methotrexate perioperatively have not show

17、n an increased risk of infection. In general, use of methotrexate should not be discontinued perioperatively. 很多研究都顯示，術(shù)前應(yīng)用甲氨蝶呤并不會(huì)增加感染的風(fēng)險(xiǎn)。 通常情況下，術(shù)前不停用甲氨蝶呤。 Patients with renal insufficiency (preoperatively or postoperatively), poorly controlled diabetes, lung or liver disease, or a history of alcohol

18、 abuse should discontinue using methotrexate preoperatively. This recommendation is especially important for patients undergoing high-stress procedures such as an arthroplasty or tumor resection. 如患者伴有腎功能不全（術(shù)前或術(shù)后），糖尿病控制不佳，肺或肝臟疾病，或者酗酒都應(yīng)該在術(shù)前停用甲氨蝶呤。 如患者需要進(jìn)行應(yīng)激較大的手術(shù)，比如關(guān)節(jié)置換或腫瘤切除手術(shù)等，這一建議則尤為重要。Other Disease

19、-Modifying Antirheumatic Drugs其他緩解病情的抗風(fēng)濕類(lèi)藥物 Very little data are available to enable one to make recommendations about these medications。 Consultation with a rheumatologist preoperatively is highly recommended. 對(duì)于這一類(lèi)藥物，幾乎沒(méi)有相關(guān)的數(shù)據(jù)可供參考。 對(duì)此，在術(shù)前請(qǐng)風(fēng)濕科醫(yī)生會(huì)診則是非常明智的。 Biologics: Tumor-Necrosis-Factor (TNF) Anta

20、gonists and Interleukin-1 (IL-1) Antagonists生物制劑：腫瘤壞死因子（TNF）拮抗劑和白細(xì)胞介素-1（IL-1）拮抗劑 There are minimal data and experience on which to base strict recommendations about either of these classes of drugs. Serious infection is a known complication of TNF-inhibitor therapy. Perioperative use of such therapy

21、 has been shown to be safe in foot and ankle surgery. 對(duì)以上兩類(lèi)藥物，目前相關(guān)的數(shù)據(jù)和經(jīng)驗(yàn)都極為有限. 嚴(yán)重的感染是TNF拮抗劑治療的一個(gè)重要的并發(fā)癥。 有研究證明，在足踝外科手術(shù)的圍手術(shù)期應(yīng)用這些藥物是安全的。 At this time, a conservative approach should be taken. For patients undergoing intensive procedures in particular, these medications should be withheld preoperatively

22、 for at least one dosing cycle and postoperatively until adequate wound-healing is observed. 此時(shí)，采取保守一些的方法還是比較可取的。 尤其對(duì)于手術(shù)較大的患者， 這些藥物應(yīng)在術(shù)前停用至少一個(gè)療程， 并在術(shù)后創(chuàng)口愈合后再考慮續(xù)用。Human Immunodeficiency Virus (HIV)人類(lèi)免疫缺陷病毒（HIV） The increased longevity of HIV-positive patients has created a new subset of potential candi

23、dates for total joint replacements and other orthopaedic procedures. Several retrospective reports, most involving small numbers of patients, have provided mixed results. 隨著HIV陽(yáng)性患者的壽命不斷延長(zhǎng)，在適合做全關(guān)節(jié)置換和其他骨科手術(shù)的患者人群中也增加了這樣一個(gè)亞組。 有幾項(xiàng)回顧性的病例報(bào)告，大多樣本量都較小，相關(guān)的結(jié)果差別也很大。 Whereas some studies showed an alarming rate

24、of postoperative infection in these patients, other studies did not. Prospective randomized studies on this topic are lacking. 有的研究顯示這些患者術(shù)后出現(xiàn)高的驚人的感染率，而另外一些研究的結(jié)果則并非如此。 對(duì)這一問(wèn)題目前尚缺乏前瞻性的隨機(jī)研究。Diabetes Mellitus and Hyperglycemia糖尿病和高血糖 Diabetes has been associated with an increased risk of surgical site in

25、fection 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 more detrimental. 在骨科的多個(gè)領(lǐng)域中，糖尿病都會(huì)增加手術(shù)部位感染的風(fēng)險(xiǎn)。 雖然，從某種程度上說(shuō)，“

26、糖尿病的不利之處”可能與糖尿病所引起的病理改變有關(guān)， 然而，圍手術(shù)期急性的高血糖效應(yīng)則可能更為不利 The increased risk of infection in diabetics undergoing orthopaedic surgery is often associated with complications related to wound-healing . To achieve appropriate wound-healing in diabetic patients, their nutritional status and insulin regimen must

27、 be optimized before they undergo any surgical procedure. 進(jìn)行骨科手術(shù)的糖尿病患者感染的風(fēng)險(xiǎn)較高，這通常與創(chuàng)口愈合相關(guān)的并發(fā)癥有關(guān)（圖2）。 為了使糖尿病患者的創(chuàng)口能順利愈合，在進(jìn)行任何手術(shù)之前，應(yīng)該使其營(yíng)養(yǎng)狀況和胰島素的用法都調(diào)整到最佳的狀態(tài)。Fig. 2 Infected wound dehiscence in a sixty-three-year-old woman with poorly controlled insulin-dependent diabetes who underwent a total knee replac

28、ement.圖2 女性，63歲，行全膝關(guān)節(jié)置換術(shù)，胰島素依賴(lài)型糖尿病控制不佳，創(chuàng)口感染開(kāi)裂。 A recent study evaluating surgical site infection following orthopaedic spinal surgery identified hyperglycemia in patients not previously diagnosed with diabetes as a potential risk factor。 最近有一項(xiàng)評(píng)價(jià)骨科脊柱手術(shù)后的手術(shù)部位感染的研究，將既往未曾診斷為糖尿病的患者而出現(xiàn)高血糖視為一個(gè)潛在的危險(xiǎn)因素。 Maln

29、utrition Malnutrition is a known risk factor for deep infection 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 nutrit

30、ional status checked preoperatively.營(yíng)養(yǎng)不良 大家知道，營(yíng)養(yǎng)不良對(duì)于各種骨科手術(shù)的深部感染都是一個(gè)風(fēng)險(xiǎn)因素。 有些患者通常伴有營(yíng)養(yǎng)不良的相關(guān)風(fēng)險(xiǎn)，如患有胃腸道疾病、腎功能不全、酗酒、癌癥或其他慢性病的老年患者。因此，術(shù)前應(yīng)該對(duì)這些患者的營(yíng)養(yǎng)狀況進(jìn)行認(rèn)真的檢查 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 increas

31、ed rate of wound complications. 有研究顯示，淋巴細(xì)胞總數(shù)1500/mm3（1.5109/L），血清白蛋白水平3.5g/dL，或轉(zhuǎn)鐵蛋白水平103/mL on urine culture 我們結(jié)合相關(guān)文獻(xiàn)，提出以下的一些建議： 做尿液分析和尿培養(yǎng)。 如有以下情況，應(yīng)該考慮推遲手術(shù)，高風(fēng)險(xiǎn)患者尤其如此：術(shù)前評(píng)估顯示有尿道梗阻的相關(guān)癥狀?；颊哂信拍蚶щy和尿頻等癥狀，同時(shí)尿培養(yǎng)顯示尿菌落計(jì)數(shù)103/mL。Preoperative Anemia Some reports have indicated that post-operative anemia treated w

32、ith 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 transfusions is diminished. 術(shù)前貧血 有研究報(bào)告指出,同種異體輸血來(lái)治療術(shù)后貧血是手術(shù)部位感染的風(fēng)險(xiǎn)因素之一。 有幾項(xiàng)研究顯示，當(dāng)術(shù)前貧血糾正后，術(shù)后外源性輸血的風(fēng)險(xiǎn)便可大大減少 Scre

33、ening for preoperative anemia and correcting the condition through the use of recombinant human erythropoietin (epoetin alfa) therapy has been studied in orthopaedic patients and has proven to be beneficial in some but not all instances. Epoetin alfa directly increases preoperative red-blood-cell ma

34、ss, hemoglobin concentration, and hematocrit levels. Even when a patient has chosen to donate autologous blood preoperatively, erythropoietin may be used as an adjunct。 對(duì)術(shù)前貧血進(jìn)行篩查，并通過(guò)應(yīng)用重組人紅細(xì)胞生成素（epoetin alfa，阿法依泊?。┻M(jìn)行治療以糾正這種狀況，這一方法已有學(xué)者在骨科患者中進(jìn)行過(guò)研究，結(jié)果證明，對(duì)有些病例但并不是所有病例都有效。 阿法依泊汀可直接增加術(shù)前血紅細(xì)胞總量、血紅蛋白濃度和紅細(xì)胞壓積水

35、平。 即便對(duì)選擇術(shù)前留取自體血的患者，也可輔助性地應(yīng)用促紅細(xì)胞生成素。 Lastly, iron deficiency has been shown to be a common reason for failure of erythropoietin treatment, so iron levels need to be supplemented while the patient is being treated with recombinant erythropoietin. 最后，已有研究證實(shí)，鐵缺乏是導(dǎo)致促紅細(xì)胞生成素治療失敗的常見(jiàn)原因， 因此，對(duì)準(zhǔn)備應(yīng)用重組人紅細(xì)胞生成素進(jìn)行治療

36、的患者，有必要適當(dāng)補(bǔ)充鐵劑。Local or Remote Orthopaedic Infections Prior surgery increases the rate of deep infection after revision arthroplasty procedures. A history of an infection following the primary arthroplasty procedure increases the risk of an infection after the revision arthroplasty. 先前的手術(shù)會(huì)增加關(guān)節(jié)翻修手術(shù)后深部

37、感染的幾率。 如果初次關(guān)節(jié)置換手術(shù)后曾有感染的病史，則會(huì)使關(guān)節(jié)翻修手術(shù)后感染的風(fēng)險(xiǎn)增加。 An elevated leukocyte count with differential, erythrocyte sedimentation rate(ESR), and C-reactive protein (CRP) level should raise the suspicion of an underlying infection. If one of these values is elevated in a patient scheduled for arthroplasty, additional preoperative testing (aspiration and bone marrow/white-blood-cell scan) or intraoperative testing (cell counts and frozen-section sampling) should be done. 如果白細(xì)胞分類(lèi)計(jì)數(shù)、紅細(xì)胞沉降率（ESR）和C反應(yīng)蛋白（CRP）水平升高，應(yīng)考慮潛在感染