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典型案例分析骨水泥与VSD负压引流治疗糖尿病人后背感染为何无效

2019-05-31 袁敏琴 健康号

患者乔某奇来自于安徽省淮南市,患有糖尿病、冠心病等慢性病多年,并于8个月前(以我院住院时间计)在当地某医院做了冠动脉支架植入术。术后本来就在康复期,结果一个月之后腰、背部等起了“痈”,特别瘙痒,结果抓挠有点过度了,后背的皮肤出现破损和红肿。

患者乔某奇来自于安徽省淮南市,患有糖尿病、冠心病等慢性病多年,并于8个月前(以我院住院时间计)在当地某医院做了冠动脉支架植入术。术后本来就在康复期,结果一个月之后腰、背部等起了“痈”,特别瘙痒,结果抓挠有点过度了,后背的皮肤出现破损和红肿。

“痈”好发于免疫力低下的人,糖尿病是其好发的人群之一,加上刚做完手术,就出现了几个“痈”。“痈”本身就有一个特点,就是红肿热痛,未脓易消,已脓易溃。再加上他本身就是糖尿病患者,后背有一处伤口逐渐破溃和疼痛,就去了附近的诊所换药,但是伤口仍继续溃烂。

病人和家属们都感觉到不正常,也担心伤口会进一步加剧,于三个月前在家属陪同下就诊于淮南市某人民医院,医生给他做了“背痈溃疡扩创+清创术”。原本以为去了医院,也做了手术了,肯定就没有问题了!让大家百思不得其解的是,为什么一直在治疗,伤口不但没有好转,反而继续恶化呢?

为了避免伤口进一步扩大,经过查阅资料,患者于50天前去了蚌埠某医学院附属某医院的整形烧伤科治疗,因为他们的专长之一就是治疗慢性不愈合创面,在周边地区具有一定的声誉。

到了医院,医生给患者的背部多次行“背部创面扩创术+骨水泥复合万古霉素填充+VSD术”,并给予输液抗菌药物应用,但是病情依然无好转,溃疡呈现进行性增大。这里不得不说一下骨水泥和VSD负压引流,这也恰恰是我们医院不推荐采用的方法!

关于骨水泥:骨水泥是最近几年发展起来的新技术,主要用于骨折、腰椎疾病及关节置换与固定手术等领域,优势也很明显。最近不断有骨水泥治疗糖尿病足等慢性骨髓炎的报道,我认为必须根据实际情况去选择,要综合评估骨水泥的适应症和禁忌症,绝对不能盲目求新求异,避免让患者遭受本可以避免的不幸。

糖尿病的伤口不但是骨组织感染或缺损的问题,重要的是伤口的难愈合,感染难控制。即便往骨水泥材料里面添加一定的抗生素,根据我院收治的好多案例看,结果都是不能控制糖尿病人的伤口感染,都导致了伤口的加重。因此,对于糖尿病人的伤口感染,尤其是伴有较深足部感染的病人,是骨水泥的禁忌症,不建议做骨水泥。

关于负压引流:封闭式负压引流技术,简单说就是通过把生物半透膜等覆盖在伤口表面创造一个密闭的环境,然后利用负压机等设备给伤口创造一个负压环境,通过引流管持续把感染的炎性组织脓液等吸出,起到清创与引流的目的。

特别是对于严重感染的伤口,多伴有深部组织感染,有隐匿性的窦道和瘘洞,如果没有人为手术清创的话,单纯用负压引流根本无法引流通畅,无法引流干净。相反,压力会进一步刺激伤口进一步缺氧缺血,厌氧菌加速繁殖,进而加速周边健康组织的感染与坏死,后果很严重。因此,对于伴有较深组织感染的糖尿病人伤口,要慎重采用负压引流。

再说这个患者,就诊的这家医院对他同时采用了骨水泥和负压引流治疗,我们不得不问几个问题:有没有综合评估两种方法的适应症和禁忌症?有没有忽略糖尿病对伤口愈合的影响?有没有针对血糖高的病人制定差别化的治疗方案?

还是越治越严重,位置又比较特殊,再继续感染和扩创下去,会不会破坏到脊髓?大家都非常焦急,后转到我科。经过全体医护人员的共同努力,他后背上的深腔逐渐长满了新鲜的肌肉等组织,这在很多同行医生眼里都是不可能的。而把“不可能”变为“可能”,就是一种成功。

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    2019-10-05 ZGMFX24A
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    2019-05-31 misszhang

    谢谢MedSci提供最新的资讯

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