脊柱术后伤口感染 .ppt

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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Surgical Site Infection(SSI)SSI was defined as:any postoperative wo

2、und 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 deformity surgery:an analysis of patient risk Eur Spine J(20

3、10)19:982988SSI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 organismsJENNIFERB.MASSIE B,S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99

4、-108Surgical 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 at the site of the surgery within 30 days after the operation or within 1 year if the operation inc

5、luded 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 fusionEur Spine J(2010)19:17111719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

6、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0.712%。46/830(5.0%),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 p

7、atient risk Eur Spine J(2010)19:98298836/1,568（2.2%）J.J.P.Schimmel P.P.Horsting M.de Kleuver G.Wonders J.van Limbeek Risk factors for deep surgical site infections after spinal fusionEur Spine J(2010)19:17111719SSI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)

8、and history of prior SSI(P=0.045)significantly increased the risk of SSIAlbert 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危险因素吸烟史 smoking showed a significant

9、 difference between the groups 肥胖 A nearly 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 infection

10、s after spinal fusionEur Spine J(2010)19:17111719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 3.70J.J.P.Schimmel P.P.Horsting M.de Kleuv

11、er G.Wonders J.van Limbeek Risk factors for deep surgical site infections after spinal fusionEur Spine J(2010)19:17111719危险因素-手术时间an increased operating time will result in significant increased risk for SSIPull ter Gunne AF,Cohen DB(2009)Incidence,prevalence andanalysis of risk factors for surgical

12、 site infection following adultspinal surgery.Spine(in press）危险因素-手术时间Surgical literature documents that operations lasting longer than 5 hours have increased wound-infection ratesJohnston,D.H.,Fairclough,J.A,and Brown.E.M.:Microbial surveillance in the surgical intensive care unit.Surg.Gynecol.Obst

13、et.I39:32 1,1974SSI 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 an abces or other signs of infection at observation,re-operation,histo-pa

14、thological or radiological investigation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.3:99,1972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Kelle

15、r,R.B.,and Pappas,A.M.:Infections after spinal fusion using internal fixation instrumentation.Orthop.Clin.North Am.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.de Kleuver G.Wonders J.van Limbeek Risk factors for deep surgica

16、l site infections after spinal fusionEur Spine J(2010)19:17111719致病菌The most common organism cultured was Staphylococcus aureus 金黄色葡萄球菌High-risk patients should be informed about the increased risk of complications细菌学46 patients had single organisms isolated and 28 patients had polymicrobial infecti

17、ons.丙酸杆菌 34金葡 32表皮葡萄球菌 18Iona Collins The diagnosis and management of infection following instrumented spinal fusion.Eur Spine J(2008)17:445450Micro-organism(s)Number of cases金葡 27E.colib 1Proteus mirabilis 1CNSAc 2Streptococcus 1Enterococcus 1CNSAc?S.aureusa 1Enterobacter?S.aureusa 1Enterococcus?S.

18、aureusa 1Gram Positive金黄色葡萄球菌 12表皮葡萄球菌8Enierococcirs.faecalis 2Strepiococciis viridans 1Diphtheroids IPropionihacteriiitn ucnes 1Peptococcus species(anaerobe)3species(anaerohe)IGram Negative阴沟场杆菌 4Serratis murcescens IPseudomonas aeriiginosa 1Pseiidotnonas maltophilia 1Acinetobacler anilratiis IBuct

19、eroides species(anaerobe)3Closirodium dijicile(anaerobe)I12*Peptostreptococcirs伤口感染的预防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 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 excessive movement in the operating room add still

20、 further risk of airborne contamination外科医生Double gloving and periodic routine outer glove changes should be considered in lengthy cases患者术前洗澡会阴冲洗Locally traumatized areas should be allowed to heal before an incision is madeJENNIFERB.MASSIE B,S Postoperative Posterior Spinal Wound Infections。Clinica

21、l Orthopaedics and Related Research 1992；284：99-108抗生素The role of prophylactic antibiotics in spinalsurgery 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 Curtin,J.A,:Prophylactic antibiotics and wound infections following laminectomy for lumbar disc herniation-a retros

22、pective study.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a solution of povidoneiodine(PVPI)and hydrogen peroxide(H2O2).reducing the rate of post-operativeinfection in spine surgery.7/460 to 0/490Simone Ulivieri Prevention of post-operative infections in spine surgery by woun

23、d irrigation with a solution of povidoneiodine and hydrogen peroxide Arch Orthop Trauma Surg 2011ChengMT,ChangMC,Wang ST,YuWK,LiuCL,ChenTH(2005)Efficacy of dilute betadine solution irrigation in the prevention ofpostoperative infection of spinal surgery.Spine 30:16891693治疗怀疑伤口感染需要及时、积极、手术treatment o

24、f the suspected infection should be prompt,aggressive,and surgical抗生素需要及时应用Antibiotic treatment is usually adjunctive and follows definitive surgical debridementOxford Skeletal InfectionResearch and Intervention Service(OSIRIS)eight tissue samples taken from areas immediately adjacent to the instrum

25、entation,along the length of the woundSix samples were sent for microbiology culture and microscopy and two were immediately fixed in formalinand sent for histological examination 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early surgical intervention with incision,irrigation,and debridement特别是存在金属内固定、骨移植、硬膜

26、暴露情况particularly in the presence of metallic implants,bone graft,and exposed dura,appear to exceed the risks of delayMichael T.Rohmiller,Closed Suction Irrigation for the Treatment ofPostoperative Wound Infections Following Posterior Spinal Fusion and InstrumentationSPINE Volume 35,Number 6,pp 64264

27、6Closed suction irrigationsystem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真空负压吸引Ludwig Labler,Marius Keel,Otmar Trentz Michael Heinzelmann Wound conditioning by vacuum as

28、sisted closure(V.A.C.)in postoperative infections after dorsal spine surgery Eur Spine J(2006)15:13881396真空负压吸引真空负压吸引V.A.C.TM dressing was changed after 3 days in anaverage(range:17 days)only during repeated second look operations and performed 3.8 times in an average14/15 治愈率内固定保留与否28/33 cases with

29、 spinal implants(85%)it was possible to leave the implants in situ and obtain healing of the infectionJENNIFERB.MASSIE B,S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99-108内固定的命运at the time of diagnosis of infection.If unfused,each patient was

30、 given 6 weeks of intravenous antibiotics,then oral antibiotics until fusion was complete and the implants were then removedIn the fused spine,the management depended on the nature of the pathogen.Iona Collins The diagnosis and management of infection following instrumented spinal fusion.Eur Spine J

31、(2008)17:445450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 2.91.7(range 0.58.0)years after the initial procedure发生率45/937(5%)late infectionsInstrumentation removal and primary wound closure are reliably curativeMichael Muschik Implant removal for late-developing i

32、nfection after instrumented posterior spinal fusion for scoliosis:reinstrumentation reduces loss of correction.A retrospective analysis of 45 cases Eur Spine J(2004)13:645651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，因为其无血供来源，易成为感染灶抗生素应用gentamycin beads were placed and left in situ for at least 2 weeksPatient

33、s were treated with intravenous antibioticsJENNIFERB.MASSIE B,S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99-108抗生素应用Antibiotic therapy was continued for at least 6 weeks following a negative culture taken during surgery in combination with a

34、 normalization of the ESR/CRP blood levelsJENNIFERB.MASSIE B,S Postoperative Posterior Spinal Wound Infections。Clinical Orthopaedics and Related Research 1992；284：99-108抗生素的应用The median duration of intravenous antibiotic administration following implants removal was 4 weeks(4 days to 8 weeks）median

35、duration of oral antibiotic administration was 5 weeks(nil given to 1 year and 6 months duration)Iona Collins The diagnosis and management of infection following instrumented spinal fusion.Eur Spine J(2008)17:445450抛砖引玉脊柱手术的伤口感染问题还没有解决好，如何尽量减少此类并发症，望各位同道群策群力，同掌江湖需要探讨的问题SSI的定义早期感染和迟发感染的时间界定SSI的诊断标准SSI的治疗准则（手术方式、抗生素等）SSI患者内固定处理原则谢谢大家！