1、外科手术部位感染的可控性因素 目前差不多明确,骨科手术部位的感染包括多方面的风险因素,如各种不同的人群、合并症、手术以及术后相关的因素等 The patient as a host is an important risk factor for infection,and many,if not most,patients are in suboptimal health、患者作为宿主本身就是感染最重要的风险因素,即使不是大多数,那也有特别多患者的健康状况并不理想。Optimizing the patients medical condition before surgery and elim
2、inating or even diminishing modifiable risk factors for infection(Fig、1)should lower the risk of surgical site infection、在手术前将患者的内科情况调整到最佳状态,杜绝或减少感染的可控性风险因素(图1)应该能够降低手术部位感染的风险。Direct scientific evidence showing that modification of these risk factors will lead to a decrease in surgical site infectio
3、n is not readily available,and much work in this field remains to be done、然而,关于控制这些风险因素便可减少手术部位感染的观点,要找到直截了当的科学证据事实上并不简单,在这一领域仍有特别多工作有待进一步深入。It is imperative that surgeons have an extensive knowledge of modifiable risk factors affecting the wound-healing process and subsequent wound plications、特别必要的
4、是,外科医生应该对影响创口愈合过程以及继发创口并发症的可控性风险因素有一个广泛的认识。Modifiable Risk Factors for Surgical Site Infection and Possible Preoperative Interventions手术部位感染的可控性风险因素及估计的术前干预措施Rheumatoid Arthritis Patients with rheumatoid arthritis have an increased risk of infection following orthopaedic procedures、Patients with rhe
5、umatoid 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、类风湿性关节炎 患有类风湿性关节炎的患者骨科手术后感染的风险明显增加。类风湿性关节炎类风湿性关节患者行全关节置换术后发生手术部位感染的风险是骨关节炎患者的2-3倍。Patients with rheumatoid arthritis
6、 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 wound-healing and the risk of infection、类风湿性关节炎的患者常常要服用多种药物,包括非甾体类抗炎药、皮质类固醇、氨甲喋呤及生物制剂等,所有这些都会对创口愈合以及感染的风险产生影响。There are in
7、sufficient data from patients who have undergone orthopaedic procedures to make evidence-based remendations about the majority of these medications、目前关于大多数该类药物而言,来自骨科手术患者的数据并尚不足以给出明确的循证医学建议。A good working relationship with the patients rheumatologist is critical to making decisions about these medic
8、ations、应注意与患者的风湿科医生保持紧密的联系,以决定这些药物的应用方案。Synthesis of the available data suggests the following、综合现有的数据可得出以下建议Nonsteroidal Anti-Inflammatory Drugs 非甾体类抗炎药 While nonsteroidal anti-inflammatory drugs do not seem to increase transfusion requirements,morbidity,and mortality directly,they may increase int
9、raoperative and postoperative bleeding、Increased bleeding may lead to a postoperative infection、尽管非甾体类抗炎药好像并可不能直截了当增加输血的需求、致残率及致死率,但这些药物估计会增加术中和术后的出血量。出血增加估计导致术后感染。Use of medications with short half-lives(ibuprofen and indomethacin)should be discontinued one to two days before surgery、Use of drugs w
10、ith 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、半衰期较短的药物(布洛芬和吲哚美辛)应在术前1-2天停药,半衰期较长的药物(萘普生)应在术前3天停药,而阿斯匹林应在术前7-10天停药,以便让未受影响的血小板再生。While cyclooxygenase-2(C
11、OX-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 are controversial with regard to the best way to handle these newer drugs、尽管环氧化酶-2(CO
12、X-2)特异性抑制的非甾体类抗炎药估计并不像非COX-2特异性抑制的非甾体类抗炎药那样与出血量紧密相关,还估计会影响骨愈合,但关于应用这些新药的最佳方案,相关的数据仍然存在争议。Corticosteroids皮质类固醇 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
13、 general,all patients on chronic corticosteroid therapy should receive their regular dose of corticosteroids perioperatively、皮质类固醇的剂量应用不合理可导致疾病发作,同时在一些较为少见的情况下,还估计出现肾上腺功能不全。有研究显示皮质类固醇会增加感染率,影响创口愈合。通常情况下,所有长期接受皮质类固醇治疗的患者在围手术期仍应该依照标准剂量服用皮质类固醇。The use of stress dose steroids remains controversial,and g
14、uidelines 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 factors for i
15、nfection、应用大剂量的类固醇目前仍有争议,指南也特别难确立。大剂量类固醇不应该作为常规来应用,但应该依照应用某种类固醇的持续时间,能够预见的手术相关的应激水平,以及存在感染的其他风险因素等情况,进行个体化的处理。Methotrexate甲氨蝶呤 Most studies on the use of methotrexate perioperatively have not shown an increased risk of infection、In general,use of methotrexate should not be discontinued perioperative
16、ly、特别多研究都显示,术前应用甲氨蝶呤并可不能增加感染的风险。通常情况下,术前不停用甲氨蝶呤。Patients with renal insufficiency(preoperatively or postoperatively),poorly controlled diabetes,lung or liver disease,or a history of alcohol abuse should discontinue using methotrexate preoperatively、This remendation is especially important for patien
17、ts undergoing high-stress procedures such as an arthroplasty or tumor resection、如患者伴有肾功能不全(术前或术后),糖尿病控制不佳,肺或肝脏疾病,或者酗酒都应该在术前停用甲氨蝶呤。如患者需要进行应激较大的手术,比如关节置换或肿瘤切除手术等,这一建议则尤为重要。Other Disease-Modifying Antirheumatic Drugs其他缓解病情的抗风湿类药物 Very little data are available to enable one to make remendations about t
18、hese medications。Consultation with a rheumatologist preoperatively is highly remended、关于这一类药物,几乎没有相关的数据可供参考。对此,在术前请风湿科医生会诊则是特别明智的。Biologics:Tumor-Necrosis-Factor(TNF)Antagonists and Interleukin-1(IL-1)Antagonists生物制剂:肿瘤坏死因子(TNF)拮抗剂和白细胞介素-1(IL-1)拮抗剂 There are minimal data and experience on which to b
19、ase strict remendations 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、对以上两类药物,目前相关的数据和经验都极为有限、严重的感染是TNF拮抗剂治疗的一个重要的并发症。有研究证明,在足踝外科手术的围手术期应用这些药物是安全的。At this ti
20、me,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、此时,采取保守一些的方法依然比较可取的。尤其关于手术较大的患者,这些药物应在术前停用至少一个疗程,并在术后创口
21、愈合后再考虑续用。Human Immunodeficiency Virus(HIV)人类免疫缺陷病毒(HIV)The increased longevity of HIV-positive patients has created a new subset of potential candidates for total joint replacements and other orthopaedic procedures、Several retrospective reports,most involving small numbers of patients,have provided
22、mixed results、随着HIV阳性患者的寿命不断延长,在适合做全关节置换和其他骨科手术的患者人群中也增加了如此一个亚组。有几项回顾性的病例报告,大多样本量都较小,相关的结果差别也特别大。Whereas some studies showed an alarming rate of postoperative infection in these patients,other studies did not、Prospective randomized studies on this topic are lacking、有的研究显示这些患者术后出现高的惊人的感染率,而另外一些研究的结果则
23、并非如此。对这一问题目前尚缺乏前瞻性的随机研究。Diabetes Mellitus and Hyperglycemia糖尿病和高血糖 Diabetes has 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
24、 more likely that the acute effects of perioperative hyperglycemia are even more detrimental、在骨科的多个领域中,糖尿病都会增加手术部位感染的风险。尽管,从某种程度上说,“糖尿病的不利之处”估计与糖尿病所引起的病理改变有关,然而,围手术期急性的高血糖效应则估计更为不利 The increased risk of infection in diabetics undergoing orthopaedic surgery is often associated with plications related
25、 to wound-healing、To achieve appropriate wound-healing in diabetic patients,their nutritional status and insulin regimen must be optimized before they undergo any surgical procedure、进行骨科手术的糖尿病患者感染的风险较高,这通常与创口愈合相关的并发症有关(图2)。为了使糖尿病患者的创口能顺利愈合,在进行任何手术之前,应该使其营养状况和胰岛素的用法都调整到最佳的状态。Fig、2 Infected wound dehi
26、scence in a sixty-three-year-old woman with poorly controlled insulin-dependent diabetes who underwent a total knee replacement、图2 女性,63岁,行全膝关节置换术,胰岛素依赖型糖尿病控制不佳,创口感染开裂。A recent study evaluating surgical site infection following orthopaedic spinal surgery identified hyperglycemia in patients not prev
27、iously diagnosed with diabetes as a potential risk factor。最近有一项评价骨科脊柱手术后的手术部位感染的研究,将既往未曾诊断为糖尿病的患者而出现高血糖视为一个潜在的危险因素。Malnutrition 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 wh
28、o have gastrointestinal diseases,renal failure,alcoholism,cancer,or any chronic disease,should have their nutritional status checked preoperatively、营养不良 大伙儿明白,营养不良关于各种骨科手术的深部感染都是一个风险因素。有些患者通常伴有营养不良的相关风险,如患有胃肠道疾病、肾功能不全、酗酒、癌症或其他慢性病的老年患者。因此,术前应该对这些患者的营养状况进行认确实检查 A total lymphocyte count of 1500/mm3(1、5
29、109/L),a serum albumin level of3、5 g/dL,or a transferrin level of 226mg/Dl has been associated with an increased rate of wound plications、有研究显示,淋巴细胞总数1500/mm3(1、5109/L),血清白蛋白水平3、5g/dL,或转铁蛋白水平103/mL on urine culture 我们结合相关文献,提出以下的一些建议:做尿液分析和尿培养。如有以下情况,应该考虑推迟手术,高风险患者尤其如此:术前评估显示有尿道梗阻的相关症状。患者有排尿困难和尿频等症状
30、,同时尿培养显示尿菌落计数103/mL。Preoperative Anemia Some 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 transfu
31、sions is diminished、术前贫血 有研究报告指出,同种异体输血来治疗术后贫血是手术部位感染的风险因素之一。有几项研究显示,当术前贫血纠正后,术后外源性输血的风险便可大大减少 Screening for preoperative anemia and correcting the condition through the use of rebinant human erythropoietin(epoetin alfa)therapy has been studied in orthopaedic patients and has proven to be beneficial
32、 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 used as an adjunct。对术前贫血进行筛查,并通过应用重组人红细胞生成素(epoetin alfa,阿法依泊汀
33、)进行治疗以纠正这种状况,这一方法已有学者在骨科患者中进行过研究,结果证明,对有些病例但并不是所有病例都有效。阿法依泊汀可直截了当增加术前血红细胞总量、血红蛋白浓度和红细胞压积水平。即便对选择术前留取自体血的患者,也可辅助性地应用促红细胞生成素。Lastly,iron deficiency has been shown to be a mon reason for failure of erythropoietin treatment,so iron levels need to be supplemented while the patient is being treated with r
34、ebinant erythropoietin、最后,已有研究证实,铁缺乏是导致促红细胞生成素治疗失败的常见原因,因此,对准备应用重组人红细胞生成素进行治疗的患者,有必要适当补充铁剂。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
35、 the risk of an infection after the revision arthroplasty、先前的手术会增加关节翻修手术后深部感染的几率。假如初次关节置换手术后曾有感染的病史,则会使关节翻修手术后感染的风险增加。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 the
36、se 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、假如白细胞分类计数、红细胞沉降率(ESR)和C反应蛋白(CRP)水平升高,应考虑潜在感染的估计性。假如准备行关节置换手术的患者这些指标中有一项增高,则应
37、该在术前再做一次检测(抽吸和骨髓/白细胞检测)或术中检测(细胞计数和冰冻切片检查)。othersColonization with Staphylococcus aureus There is a strong association between nasal carriage of Staphylococcus aureus and development of Staphylococcus aureus surgical site infections、A preoperative screening and topical decolonization protocol that has been proposed and studied at length includes mupirocin ointment to the nares twice daily、感谢您的聆听！感谢您的聆听！
