外科手術部位感染的可控性因素-課件

1、外科手術部位感染的可控性因素 外科手術部位感染的可控性因素 目前差不多明確,骨科手術部位的感染包括多方面的風險因素,如各種不同的人群、合并癥、手術以及術后相關的因素等 目前差不多明確,骨科手術部位的感染包括多方面的風險因素,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患者作為宿主本身就是感染最重要的風險因素,即使不是大多數(shù),那也有特

2、別多患者的健康狀況并不理想。 患者作為宿主本身就是感染最重要的風險因素,即使不是大多數(shù),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在手術前將患者的內(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險因素(

3、圖1)應該能夠降低手術部位感染的風險。 在手術前將患者的內(nèi)科情況調(diào)整到最佳狀態(tài),杜絕或減少感染的可控外科手術部位感染的可控性因素-課件外科手術部位感染的可控性因素-課件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,關于控制這些風險因素便可減少手術部位感染的觀點,要找到直截了當?shù)目茖W證據(jù)事實上并不簡單,在這一領域仍有特別多工作有待進一步深入。 然而,關于控制這些風險因素便可減少手術部位感染的觀點,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特別必要

5、的是,外科醫(yī)生應該對影響創(chuàng)口愈合過程以及繼發(fā)創(chuàng)口并發(fā)癥的可控性風險因素有一個廣泛的認識。特別必要的是,外科醫(yī)生應該對影響創(chuàng)口愈合過程以及繼發(fā)創(chuàng)口并發(fā)Modifiable Risk Factors for Surgical Site Infection and Possible Preoperative Interventions手術部位感染的可控性風險因素及估計的術前干預措施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 類風濕性關節(jié)炎患有類風濕性關節(jié)炎的患者骨科手術后感

7、染的風險明顯增加。類風濕性關節(jié)炎類風濕性關節(jié)患者行全關節(jié)置換術后發(fā)生手術部位感染的風險是骨關節(jié)炎患者的2-3倍。類風濕性關節(jié)炎患有類風濕性關節(jié)炎的患者骨科手術后感染的風險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類風濕性關節(jié)炎的患者常常要服用多種藥物,包括非甾體類抗炎藥、皮質(zhì)類固醇、氨甲喋呤及生物制劑等,所有這些都會對創(chuàng)口愈合以及感染的風險產(chǎn)生影響。類風濕性關節(jié)炎的患者常常要服用多種藥物,包括非甾體類抗炎藥、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目前關于大多數(shù)該類藥物而言,來自骨科手術患者的數(shù)據(jù)并尚不足以給出明確的循證醫(yī)學建議。外科手術部位感染的可控性因素-課件A good working relationship with the patients rheumatologist is critical to making decisions about these medications、A good working relationship wi應注意與患者的風濕科醫(yī)生保持緊密的聯(lián)系,以決定這些藥物的應用方案

10、。應注意與患者的風濕科醫(yī)生保持緊密的聯(lián)系,以決定這些藥物的應用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Synthesis of the available datNonsteroidal Anti-Inflammatory Drugs非甾體類抗炎藥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盡管非甾體類抗炎藥好像并可不能直截了當增加輸血的需求、致殘率及致死率,但這些藥物估計會增加術中和術后的出血量。出血增加估計導致術后感染。盡管非甾體類抗炎藥好像并可不能直截了當增加輸血的需求、致殘率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 半衰期較短的藥物(布洛芬和吲哚美辛)應在術前1-2天停藥,半衰期較長的藥物(萘普生)應在術前3天停藥,而阿斯匹林應在術前7-10天停藥,以便讓未受影響的血小板再生。半衰期較短的藥物(布洛芬和吲哚美辛)應在術前1-2天停藥, 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盡管環(huán)氧化酶-2(COX-2)特異性抑制的非甾體類抗炎藥估計并不像非COX-2特異性抑制的非甾體類抗炎藥那樣與出血量緊密相關,還估計會影響骨愈合,但關于應用這些新藥的最佳方案,相關的數(shù)據(jù)仍然存在

15、爭議。盡管環(huán)氧化酶-2(COX-2)特異性抑制的非甾體類抗炎藥估計Corticosteroids皮質(zhì)類固醇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皮質(zhì)類固醇Inadequa皮質(zhì)類固醇的劑量應用不合理可導致疾病發(fā)作,同時在一些較為少見的情況下,還估計出現(xiàn)腎上腺功能不全。有研究顯示皮質(zhì)類固醇會增加感染率,影響創(chuàng)口愈合。通常情況下,所有長期接受皮質(zhì)類固醇治療的患者在圍手術期仍應該依照標準劑量服用皮質(zhì)類固醇。皮質(zhì)類固醇的劑量應用不合理可導致疾病發(fā)作,同時在一些較為少見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應用大劑量的類固醇目前仍有爭議,指南也特別難確立。大劑量類固醇不應該作為常規(guī)來應用,但應該依照應用某種類固醇的持續(xù)時間,能夠預見的手術相關的應激水平,以及存在感染的其他風險因素等情況,進行個體化的處理。應用大劑量的類固醇目前仍有爭議,指南也特別難確立。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 特別多研究都顯示,術前應用甲氨蝶呤并可不能增加感染的風險。通常情況下,術前不停用甲氨蝶呤。 特別多研究都顯示,術前應用甲氨蝶呤并可不能增加感染的風險。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如患者伴有腎功能不全(術前或術后),糖尿病控制不佳,肺或肝臟疾病,或者酗酒都應該在術前停用甲氨蝶呤。如患者需要進

21、行應激較大的手術,比如關節(jié)置換或腫瘤切除手術等,這一建議則尤為重要。如患者伴有腎功能不全(術前或術后),糖尿病控制不佳,肺或肝臟Other Disease-Modifying Antirheumatic Drugs其他緩解病情的抗風濕類藥物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關于這一類藥物,幾乎沒有相關的數(shù)據(jù)可供參考。對此,在術前請風濕科醫(yī)生會診則是特別明智的。關于這一類藥物,幾乎沒有相關的數(shù)據(jù)可供參考。Biologics: Tumor-Necrosis-Factor (TNF) Antagonists and Interleukin-1 (IL-1) Antagonists生物制劑:腫瘤壞死因子(TNF)拮抗劑和白細胞介素-1(IL-1)拮抗劑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對以上兩類藥物,目前相關的數(shù)據(jù)和經(jīng)驗都極為有限、嚴重的感染是TNF拮抗劑治療的一個重要的并發(fā)癥。有研究證明,在足踝外科手術的圍手術期應用這些藥物是

24、安全的。 對以上兩類藥物,目前相關的數(shù)據(jù)和經(jīng)驗都極為有限、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此時,采取保守一些的方法依然比較可取的。尤其關于手術較大的患者,這些藥物應在術前停用至少一個療程,并在術后創(chuàng)口愈合后再考慮續(xù)用。此時,采取保守一些的方法依然比較可取的。Human Immunodeficiency Virus (HIV)人類免疫缺陷病毒(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 (隨著HIV陽性患者的壽命不斷延長,在適合做全關節(jié)置換和其他骨科手術的患者人群中也增加了如此一個亞組。有幾項回顧性的病例報告,大多樣本量都較小,相關的結果差別也特別大。隨著HIV陽性患者的壽命不斷延長,在適合做全關節(jié)置換和其他骨 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有的研究顯示這些患者術后出現(xiàn)高的驚人的感染率,而另外一些研究的結果則并非如此。對這一問題目前尚缺乏前瞻性的隨機研究。有的研究顯示這些患者術后出現(xiàn)高的驚人的感染率,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在骨科的多個領域中,糖尿病都會增加手術部位感染的風險。盡管,從某種程度上說,“糖尿病的不利之處”估計與糖尿病所引起的病理改變有關,然而,圍手術期急性的高血糖效應則估計更為不利在骨科的多個領域中,糖尿病都會增加手術部位感染的風險。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進行骨科手術的糖尿病患者感染的風險較高,這通常與創(chuàng)口愈合相關的并發(fā)癥有關(圖2)。為了使糖尿病患者的創(chuàng)口能順利愈合,在進行任何手術之前,應該使其營養(yǎng)狀況和胰島素的用法都調(diào)整到最佳的狀態(tài)。進行骨科手術的糖尿病患

31、者感染的風險較高,這通常與創(chuàng)口愈合相關Fig、 2 Infected wound dehiscence in a sixty-three-year-old woman with poorly controlled insulin-dependent diabetes who underwent a total knee replacement、圖2 女性,63歲,行全膝關節(jié)置換術,胰島素依賴型糖尿病控制不佳,創(chuàng)口感染開裂。外科手術部位感染的可控性因素-課件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最近有一項評價骨科脊柱手術后的手術部位感染的研究,將既往未曾診斷為糖尿病的患者而出現(xiàn)高血糖視為一個潛在的危險因素。 最近有一項評價骨科脊柱手術后的手術部位感染的研究,將既往未曾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營養(yǎng)不良大伙兒明白,營養(yǎng)不良關于各種骨科手術的深部感染都是一個風險因素。有些患者通常伴有營養(yǎng)不良的相關風險,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,術前應該對這些患者的營養(yǎng)狀況進行認確實檢查營養(yǎng)不良大伙兒明白,營養(yǎng)不良關于各種骨科手術的深部感染都是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有研究顯示,淋巴細胞總數(shù)1500/mm3(1、5109/L),血清白蛋白水平3、5g/dL,或轉鐵蛋白水平226mg/dL會增加創(chuàng)口并發(fā)癥的發(fā)生率有研究顯示,淋巴細胞總數(shù)103/mL on urine culturesome remendations、a urinalysis我們結合相關文獻,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,應該考慮推遲手術,高風險患者尤其如此:術前評估顯示有尿道梗阻的相關癥狀?；颊哂信拍蚶щy和尿頻等癥狀,同時尿培養(yǎng)顯示尿菌落計數(shù)103/mL。我們結合

36、相關文獻,提出以下的一些建議: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術前貧血有研究報告指出,同種異體輸血來治療術后貧血是手術部位感染的風險因素之一。有幾項研究顯示,當術前貧血糾正后,術后外源性輸血的風險便可大大減少 術前貧血有研究報告指出,同種異體輸血來治療術后貧血是手術部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對術前貧血進行篩查,并通過應用重組人紅細胞生成素(epoetin alfa,阿法依泊汀)進行治療以糾正這種狀況,這一方法已有學者在骨科患者中進行過研究,結果證明,對有些病例但并不是所有病例都有效。阿法依泊汀可直截了當增加術前血紅細胞總量、血紅蛋白濃度和紅細胞壓積水平。即便對選擇術前留取自體血的患者,也可輔助性地應用促紅細胞生成素。 對術前貧血進行篩查,并通過應用重組人紅細胞生成素(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,已有研究證實,鐵缺乏是導致促紅細胞生成素治療失敗的常見原因,因此,對準備應用重組人紅細胞生成素進行治療的患者,有必要適當補充鐵劑。最后,已有研究證實,鐵缺乏是導致促紅細胞生成素治療失敗的常見Local or Remote Orthopaedic Infec