最新严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例

1、严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例ACaseofCerebralMultipleAbscessOccuringWithDeepVeinCatheterRelatedInfectionAfterSeverelyBurnt患者男，36岁，因全身火焰烧伤于伤后3h入院。入院时检查：T36.1C,P96次/min,R22次/min,患者一般情况可，神志清楚，呼吸平顺，烧伤创面分布于头面、颈，躯干及四肢，创面基底大部分呈黄白色。入院诊断：烧伤总面积35%,浅II度15%,深II度20%。入院后行右侧股静脉穿刺置管常规液体复苏、创面清创，头面部暴露,四肢及躯干创面外用1%磺胺嘧啶银霜包扎等

2、治疗。入院后20h,患者面颈部、双前臂肿胀明显,自诉喉头有异物感及双手指麻木等不适,遂于局麻下行气管切开,双上肢烧伤皮肤及浅筋膜切开减压术,随后病情平稳。伤后5d在静脉全麻下行“双上肢、左小腿深II度创面15%削痂、自体网状皮移植术”，术后应用头孢哌酮+依替米星抗感染,面部深II度创面,躯干等部位创面继续外用1%磺胺嘧啶银霜隔日换药,创面分泌物未培养出细菌,术后5d,削痂植皮创面换药,皮片成活良好，伤后14d拔除气管套管，拔管后患者呼吸平顺，病情稳定，除右下腹及左足背约1%深II度创面未愈外,其余创面均愈合。治疗过程中，伤后11d开始，患者出现高热，最高达40.1C,外周血白细胞计数达20.1

3、X109/L,中心粒76%,调整抗生素为美洛西林+依替米星二联抗感染,2d后，外周血白细胞计数下降至11.4X109/L,中心粒细胞86%体温仍有波动，最高为38.9C,胸部X-线检查未见双肺有异常改变。伤后15d再次出现寒战、高热，考虑有金黄色葡萄球菌感染可能,拔除右侧股静脉导管并送细菌培养,调整抗菌素为稳可信500mgq6h静脉点滴，再次送检创面分泌物细菌培养及血培养。3d后,静脉导管、创面分泌物及血细菌培养均为耐甲氧西林金黄色葡萄球菌生长(MRS)体外药物敏感试验对万古酶素敏感，继续静滴稳可信，患者体温有所下降，但渐渐出现神情淡漠、懒言及肢体乏力等症状,静滴稳可信6d后，出现左精品文档上

4、肢肌力减退（III级），行颅脑MR检查示：右侧小脑半球及颞叶、额叶见多发片状长T1、T2信号影，境界模糊，压水序列像上呈高信号，增强扫描见明显环行强化或不完全的环形强化，局部脑沟、裂变窄，最大病灶位于右侧颞叶，大小约3cmx2.8cm,两侧大脑，左侧小脑尚可见散在小斑点样强化灶。提示两侧大脑、小脑多发性感染灶，部分脓肿形成，结合临床诊断为烧伤后颅内多发性MRSA感染，部分脓肿形成。转神经内科继续稳可信并加用磷霉素钠抗感染，甘露醇脱水降颅压等治疗，一周后，因脓肿破裂出血死亡。译文：Thepatient,male,36yearsold,wassenttohospital3hoursafterhew

5、asburntbyflamealloverhisbody.Examinationonadmission:36.1TC,P96times/min,R22times/min,patientwasinordinaryconditionwithconsciousmindandsmoothbreath.Theburntwoundspreadsinhead,neck,bodyand4limbs.Thebaseofburntwoundwasmostlyyellowishwhite.Diagnosisonadmission:Totalburntarea35%,IIdegreesuperficialburn15

6、%,IIdegreedeepburn20%.Afteradmission,thepatientreceivedtreatmentofindwellingcatheterbyrightfemoralveinpunctureconventionalfluidresuscitation,wounddebridement,headandfaceexposure,4limbsandbodywoundboundupexternallywith1%densitysulfadiazinesilverfrost,etc.20hoursafteradmission,patientsface,neckandboth

7、forearmswereobviouslyswelling.Hecomplainedtherewasmalaisefeelingofforeign-bodysensationinthroatandnumbnessinbothhandsfingers.Sotracheotomy,burntskinofbotharmsandsuperficialfasciaincisionreleasewerecarriedout.Thenthepatientsconditionwasimproving.5daysafterinjury,15%ofbotharms,leftcalfIIdegreedeepburn

8、twoundscabexcisionandmeshedautogenousskintransplantationwerecarriedoutunderintravenousanaesthesia.Afteroperation,cefoperazoneandetimicinwereusedtopreventinfection,and1%densitysulfadiazinesilverfrostwasstillappliedexternallyinIIdegreedeepburntfacewoundandbodywoundwhichwouldberefreshedonalternatedays.

9、Bacteriawasnotculturedfromwoundsecretion.5daysafteroperation,medicinewasrefreshedfor精品文档scabexcisionandskingraftingwound.Theskingraftflapwaswelldeveloped.14daysafterinjurytracheacannulaswaspulledoffandthepatientcouldbreathesmoothlyandconditionwasstable.Allwoundareaswerehealedexcept1%ofIIdegreedeepbu

10、rntwoundinrightlowerabdomenandleftdorsalispedis.Duringtreatment,since11daysafterinjury,patientwasfoundhavehighfever,andthehighesttemperaturecouldreach40.1C,thenumberofperipheralleucocytesamountedto920.1x10/Lwithcentriole76%.Theadjustingantibioticwas2-drugmezlocillinandetimicinanti-infective.2dayslat

11、er,thenumberof9peripherialleucocytedroppedto11.4x10/Lwithcentriole86%.Bodytemperatureofpatientstillhadfluctuationandthehighesttemperaturereached38.9C.ChestX-rayinspectionfoundnoabnormalchangesinbothlungs.15daysafterinjury,patientwasfoundhaveagainshiveringandhighfever.Consideringtherewaspossibilityof

12、staphylococcusaureusinfection,therightfemoralveincatheterwaspulledoffandusdforbacteriaculture,antibioticwasadjustedintovincocin500mgq6hintravenousinfusion,andthewoundsecretionwasusedagainforbacteriacultureandbloodculture.3dayslater,veincatheter,woundsecretionandbloodbacteriaculturewereallmethicillin

13、resistantstaphylococcusaureusgrow(MRSA),beingsensitivetovancomycinthroughvitrodrugsensitivitytest.Continuetointravenouslydrippinginjectwithvancomycin,patientbodytemperaturedroppedtosomeextent,butgraduallyappearedsymptomsoflookingindifference,lazyspeaking,andlimbsweakness.After6daysofintravenousinfus

14、ionofvancomycin,leftupperextremitymusclestrengthweaknesswasfound(degreeIII).Craniocerebralinspectionwasmadeandindicated:thereweremultipleflakestyleT1,T2signaldensitywithobscurerealminrightcerebellahemisphere,temporallobeandfrontlobe.Pressurizedwatersequenceimageshowedhighsignal,enhancedscanshowedevi

15、dentringenhancementorincompleteenhancement,andpartial精品文档cerebralsulcusandcerebralfissuregotnarrowed.Thebiggestfocusliedinrighttemporallobeandthesizewasabout3cmx2.8cm,andtherewerestillseperatedtinyspecksoffocusinbothsidesofbrainandleftcerebella.Itshowedtherewasmultipleinfectionfocusinbothsidesofbrai

16、nandcerebellaandsomeabscesshadformed.CombinedwithclinicdataitwasdiagnosedtobecerebralmultipleMRSAinfectionafterburntandsomeabscesshadformed.Patientwastransferredtoneurologydepartment,vancomycincontinuedtobeusedandcombinedwithfosfomycinsodiumtopreventinfectionwithtreatmentofmannitoldehydratingtoreduc

17、ecerebralpressure.Oneweeklaterpatientdiedofabscessrupture.讨论：烧伤后感染等并发症至今仍然是烧伤治疗中棘手的问题之一，特别是多重耐药细菌的感染并发症。烧伤后并发颅内感染虽然较少见，但仍有病例报道1，多见于儿童,成人也可发生。感染多为血源播散性,与严重烧伤后机体免疫功能低下易发生侵袭性感染有关，也有医源性因素如深静脉导管的相关性感染所致2。感染的病源菌多与病区优势致病菌一致，如铜绿假单胞菌、金黄色葡萄球菌等。烧伤后由耐甲氧西林的金黄色葡萄球菌（MRSA）所致的颅内感染较为少见，1992年Suzuki报道一例3。由于烧伤后颅内感染早期多与侵

18、袭性感染症状相似，易漏诊，脑膜炎症后，对MRSA敏感的抗菌素如万古霉素等难以透过血脑屏障，给治疗带来很大困难。本例烧伤面积为35%，烧伤创面主要分布在头面部和四肢暴露部位，因常用的外周静穿刺部位均被烧伤而选择了深静脉置管。在伤后2周创面基本愈合时，突发高热、白细胞增高等全身感染表现，创面分泌物、深静脉导管及血培养均培养出MRSA，结合病程、临床表现和各项检查，可诊断颅内多发性脓肿源于右股静脉导管的MRSA相关感染。尽管选用了敏感抗菌素，但万古霉素难以透过血脑屏障，局部组织难以达到有效的杀菌浓度，最终治疗失败。烧伤后留置深静脉导管，一旦发生导管感染和化脓性栓塞性静脉炎，会给后续的病灶清除术带来困

19、难，因此，有作者认为，留置导管时应尽量避免使用深静脉4。但在临床实际工作中，对大面积深度烧伤病例，留置深静脉导管有时在所难免，精品文档但要尽可能选择血流速度快，不易形成血栓的部位，如颈内静脉、锁骨下静脉等。导管留置超过7日以上,特别是股静脉部位,导管相关性感染的机率会明显增加5。因此,达到治疗目的后,应尽早拔除,需要较长时间使用的,应定期重新穿刺,更换导管。本病例入院时因四肢常用的外周静脉穿刺部位皮肤被烧伤,而选用了右股静脉穿刺置管,但未能及时更换,且留置时间过长,增加了发生导管相关感染的机会,应特别引起重视。此外,留置深静脉导管后,还应加强插管部位皮肤的护理，保持局部干燥、清洁，导管内使用抗

20、凝剂，采用抗生素锁技术等也能有效地减少深静脉导管相关性感染的发生。译文：Discussion:1992inSuzukionecasewasreported.Becouseintheearlyperiodthesymptomsofcerebralinfectionafterburntaresimilartothoseofinvasiveinfections,misseddiagnosistendstohappen.Aftermeningococcaldisease,antibioticssensitivetoMRSAsuchasvancomycinaredifficulttopasstheblo

21、od-brainbarrierwhichcausesbigdifficultiestotreatment.Inthiscasetheburntareais35%,burntwoundmainlyspreadsintheexposedpartsofhead,face,and4limbs.Becoursecommonlyusedperipheralveinpuncturepartswereallburnt,thedeepveinindwellingwasselected.精品文档Whenthewoundareawasbasicallyhealed2weeksafterinjury,symptoms

22、ofsystemicinfectionsuchashighfeverandincreasedleucocytessuddenlyoccurred.Woundsecretion,deepveincathetersandbloodcultureallculturedoutMRSA.Combinedwithdiseasecourse,clinicfeaturesandvarietyofexaminations,itcanbediagnosedthatmultiplecerebralabscesswascausedbyMRSAinrightfemoralveincatheterrelatedinfec

23、tions.Althoughsensitiveantibioticswereused,vancomycinwasdifficulttopassblood-brainbarrier,andlocaltissuewasdifficulttoachieveeffectivebactericidalconcentrationwhichleadedtotreatmentfailurefinally.Thedeepveincatheterremainedinbodyafterburnt,ifonceinfectedandsuppurativethrombophlebitishappened,willbri

24、ngdifficultiestothesubsequentdiseasefocusdebridementsurgery.Sosomeauthorthinksitshouldavoidemployingdeepveinwhileindwellingcathetersasmuchaspossible.Butinpracticalclinicwork,inextensivedeepburnmedicalcase,deepveincatheterindwellingissometimesinevitable,andtheplacewherebloodcirculatesfastandthrombusd

25、oesnoteasilyformshouldbeselected,suchasthejugularveinandsubclavianvein.Ifcatheterremainsmorethan7daysespeciallyintheplaceoffemolavein,thechanceofcatheterrelatedinfectionwillbeincreasedapperantly.Thereforethecathetershouldbepulledoffasearlyaspossibleoncethetherapeuticpurposesareachieved.Iflongtimeuse

26、isnecessary,itshouldbere-puncturedatregularintervalsandrenewthecatheter.Inthiscase,becoursethecommonlyusedperipheralveinpuncturepartsof4limbsareburntonadmission,therightfomelaveinpunctureindwellingwasselected.Butcatheterwasnotrenewedtimely,anditremainedfortoolongatimewhichincreasedthechanceofcathete

27、rrelatedinfection.Thisshouldbepaidspecialattentionto.Inaddition,afterdeepveincatheterisremained,intensivecareshouldbegiventotheskinofindwellingpartsandkeepdryandcleanlocally.Anticoagulationagentshouldbeusedincatheter,andtheantibioticlock精品文档technologycanalsoreducethechanceofdeepveincatheterrelatedinfectioneffectively.参考文献：1林源.小儿大面积烧伤晚期并发脑脓肿一例.中华烧伤外科杂志,2001,17:592.2001,27:662-663.3SuzukiT,UekiI,IsagoT,etal.Multiplebrainabscessescomplicatingtrea