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病例分享:心脏手术2年多,反复伤口渗脓和面部皮疹为哪般?

2018-01-29 黄英男 金文婷 马玉燕 SIFIC感染官微

主诉:心脏术后切口反复渗脓伴面部皮疹2年余

一、病史简介

女性,58岁,浙江人,2017-12-11入中山医院感染病科

主诉:心脏术后切口反复渗脓伴面部皮疹2年余

现病史:

2015-08因“风心二尖瓣狭窄伴关闭不全,冠心病三支病变”在外院行二尖瓣机械瓣换瓣术+冠脉搭桥术。2016-05起手术切口中下段红肿渗脓。2016-06超声:胸部正中切口皮下液性暗区(约4.3X0.9cm),予创面换药无明显好转。2016-09-23于原手术医院行胸部伤口探查+清创:胸部伤口中段可见两个小瘘口,瘘口内部可探及胸骨固定钢丝,取出钢丝2根,充分清除感染组织。术后拆线时见切口底部有中量脓液渗出,继续换药治疗。2017-01再次行胸壁清创术,取出剩余1根钢丝。2017-02切口中下部两处窦口形成伴少量脓液渗出。

2017-05-24就诊我院整形外科,行PET/CT显示,(1) 胸骨体中下部周围软组织感染,局部窦道形成可能,心包受累不除外;(2)双侧颈部、右侧锁骨区、两侧腋窝及胸腔内多发糖代谢增高的淋巴结,考虑为炎性病变可能;(3)左侧锁骨头、左侧第6前肋、右侧肱骨髓腔糖代谢增高灶。心超:人工机械二尖瓣未见明显异常。05-25送伤口脓液细菌培养:阴性。05-31起予左氧氟沙星抗感染治疗。06-02行胸骨及前纵隔感染清创+肌瓣转移+皮瓣转移。病理:(胸壁感染组织)见大片坏死,周围见组织细胞及异物巨细胞反应,炎性肉芽组织增生,伴较多淋巴细胞、浆细胞浸润,特殊染色未检出明确阳性菌。06-12出院并继续左氧氟沙星抗感染16天。

2017-11因再次出现胸部手术切口渗脓入住我院整形科。同时,患者诉2015-11起无明显诱因出现右颊部多枚丘疹样皮疹,起初范围较小,约1cm直径,无明显发红瘙痒,当地医院予药物外涂半年(具体不详),皮疹结痂。2016-05起结痂皮疹处出现水泡,伴发红,无瘙痒,范围逐渐扩大。近期面部皮疹范围进一步扩大。2017-11-14面颊皮疹处活检,病理为肉芽肿性病变,抗酸和六胺银染色均阴性。2017-11-15复查PET/CT,与05-24比较:胸骨体中下部周围软组织感染、多发炎性淋巴结、左侧锁骨头和右侧肱骨髓腔的病变范围较前缩小、糖代谢较前减低。心超同前。11-17行胸壁溃疡清创术+肌皮瓣转移术,术中见皮下组织内有一狭小窦道,内含豆渣样物。手术当天起予万古霉素抗感染7天。因感染病原体不明,为进一步诊治于12-11收治我院感染病科。

既往史个人史:20年前曾行胆囊切除术;15年前曾行阑尾切除术。








二、入院检查(2017-12-11)

体格检查:

T:36.5℃ P:86次/分 R:20次/分 BP:140/78mmHg

浅表淋巴结未及肿大。右颊可见红色成簇的丘疹,整个皮损范围约6cm直径。前胸可见长约15cm手术疤痕,局部干洁,无红肿渗出。

实验室检查:

血常规 WBC 10.05X10^9/L,N 69.3%

炎症标志物 ESR 18mm/H,CRP 11.5mg/L,PCT 0.02ng/mL

肝肾功能电解质、甲状腺功能:正常

G试验、隐球菌荚膜抗原:(-)

T-SPOT A/B:14/54

自身抗体 抗核抗体:颗粒1:100,余均(-)

肿瘤标志物:(-)

空腹血糖、糖化血糖红蛋白:正常。



三、临床分析

病史特点:患者中年女性,主要表现心脏手术2年内切口反复脓性渗液,并伴有慢性持续扩大的面部狼疮样皮疹,炎症标志物稍升高,无发热盗汗,T-SPOT阳性;PET/CT提示手术区域及附近软组织感染,以及颈部、腋下和纵膈淋巴结糖代谢增高;手术部位胸壁组织和面颊皮损处活检,均提示有肉芽肿性病变。诊断和鉴别诊断考虑如下:

1.感染性疾病:

非结核分枝杆菌(NTM)感染:心脏术后切口慢性感染,NTM是常见病原体,包括龟分枝杆菌、脓肿分枝杆菌、偶发分枝杆菌、瘰疬分枝杆菌,以及鸟-胞分枝杆菌、堪萨斯分枝杆菌等,病理常表现为肉芽肿性病变。但本例T-SPOT阳性,且斑点数较高(A和B抗原,分别为14和54),与常见NTM感染不符。当然,不排除结核和非结核分枝杆菌同时感染之可能。本病确诊有赖于分枝杆菌培养或核酸检测。

结核:患者面颊皮损持续进行性进展2年多,其形态也比较符合寻常狼疮(慢性进行性皮肤结核),结合皮肤活检和T-SPOT结果,需要怀疑皮肤结核。而同期出现的心脏手术后切口慢性感染,迁延不愈,病理也提示肉芽肿性病变,按一元论解释,则考虑结核感染可能大。但患者多次胸壁感染组织和皮肤活检组织,抗酸染色均无阳性菌发现。建议行脓液及病变组织抗酸杆菌涂片+分枝杆菌培养、核酸检测,以明确诊断。

金黄色葡萄球菌感染:金葡菌是皮肤软组织和手术切口感染的常见病原体。但金葡菌感染往往起病急,炎症标志物升高显着,伴有发热等较严重毒性症状,普通细菌培养常可分离到本菌。本例患者起病慢,病程长,炎症标记物仅稍有升高,毒性症状不明显,病理提示肉芽肿病变,故暂不考虑此诊断。

2.非感染性疾病:

患者有多处淋巴结肿大且糖代谢增高,面颊部丘疹病变等,需要考虑淋巴瘤、癌症转移、系统性红斑狼疮(SLE)等疾病,但患者胸壁坏死组织和面颊部皮损组织活检显示为肉芽肿病变,同时抗感染治疗后PET/CT显示,胸部病变范围有缩小和糖代谢下降,故此类疾病,也暂不考虑。

四、进一步检查、诊治过程和治疗反应

12-12 拟行胸骨处病灶穿刺活检术。但超声下胸骨术区未见明显脓肿形成,认为不宜穿刺。

12-13 行右颊部皮疹处再次活检。活检组织送涂片找细菌、真菌、抗酸杆菌均阴性,细菌、真菌培养阴性。病理仍显示“肉芽肿性病变”。

12-14出院等待分枝杆菌培养结果再确定具体抗感染方案



2018-01-11 皮肤活检分枝杆菌培养结果:结核杆菌阳性。

2018-01-17 开始予异烟肼+利福平+乙胺丁醇+吡嗪酰胺四联抗结核治疗。

2018-01-28 面部皮疹较前明显好转。嘱继续抗结核治疗,1月后随访胸部CT。





五、最后诊断与诊断依据

最后诊断:

多部位结核病

手术切口(胸壁)、颈和胸部淋巴结、面部皮肤

诊断依据:

中年女性,心脏术后切口反复渗脓2年,同时伴有面颊皮损持续进行性进展,其形态似寻常狼疮。PET/CT提示术区及附近软组织感染,胸部感染组织及面颊皮疹处活检均提示肉芽肿性病变,结合T-SPOT阳性,抗结核治疗2周面部皮疹明显好转,尤其是皮肤活检组织培养出结核杆菌,故本病诊断可以明确。

六、经验与体会

心脏术后切口慢性化脓感染,全身毒性症状不明显,常需考虑特殊病原体感染,特别是非结核分枝杆菌(NTM)感染,通常因手术器械消毒不合格或冲洗液体污染引起。与结核病类似,病理主要为慢性炎症伴肉芽肿。早期多表现为局部疼痛,硬结肿块,脓肿形成或破溃,皮肤溃疡等。然而,本例综合分析判断为结核分枝杆菌引起,临床甚为少见。文献报道心脏术后NTM感染平均时间为1.4 ±1.1月,而结核感染时间较NTM更长,可达13.3 ±17.1月。本例手术后9个月首次出现手术切口红肿渗脓,潜伏期长,似乎更符合结核的发病特点。

该患者除手术部位结核感染外,术后出现面颊部皮疹,通常不易将两者联系起来考虑。我院感染病科开设病房两年多来,已收治肺外结核近百例,主要为淋巴结结核、腹腔/肠结核、骨关节结核、泌尿系结核等,皮肤结核则甚少遇见。本例面颊皮疹虽有一定特征性,类似寻常狼疮表现,但由于很多临床医生缺少对本例认知和警惕性,被延误诊断超过2年。活检是诊断皮肤结核的重要手段,然而本例首次活检仅显示为“肉芽肿病变”,我们建议患者再次活检,并对标本同时进行分枝杆菌培养,才得以明确诊断。值得指出的是,先前患者胸部手术切口反复渗脓,仅做一次普通细菌培养,而未做抗酸杆菌检查和分枝杆菌培养,错过了手术部位特殊感染病原体的诊断机会。

比较困惑的是,胸部手术切口结核感染、面颊皮肤结核感染、胸腔和颈部淋巴结结核感染,三者之间的关系?同时存在手术部位及远隔部位(面颊皮肤)的结核感染,这在既往文献中罕有报道。根据通常的结核发病机制,淋巴结结核系淋巴引流处组织的结核病灶扩散导致;皮肤结核的发病包括外源性接种、局部扩散或自体接种的内源性传播、以及血行播散三条路径,而本例更倾向于血行播散所致。由此推测,本例是否首先出现手术部位(胸壁)结核感染,再引发淋巴结结核,以及血性播散导致面颊皮肤结核感染?

本例手术切口感染反复渗脓,伤口时好时坏,考虑与之前使用的抗菌药物有关。多次使用的氟喹诺酮类药物,对结核杆菌有强力杀灭作用,所以治疗后能控制病情,但单药且使用时间很短,导致一段时间后结核很快复发。这里特别需要呼吁,对于疑似结核病人,一定要加强病原学检查,并早期、联合、规律、全程使用抗结核药物。切忌不规则抗痨治疗,以免快速诱导结核菌对不规则使用的药物产生耐药,显着增加今后抗结核治疗的难度和成本,甚至让结核病成为无药可用的“不治之症”。

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    2018-01-30 神功盖世

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1819752, encodeId=85501819e52a5, content=<a href='/topic/show?id=6730998430a' target=_blank style='color:#2F92EE;'>#面部皮疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99843, encryptionId=6730998430a, topicName=面部皮疹)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad7f282, createdName=yang0210, createdTime=Tue Jun 12 02:46:00 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283467, encodeId=1b6628346e58, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Tue Jan 30 08:50:05 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283382, encodeId=6d4528338220, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue Jan 30 05:10:57 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283373, encodeId=0db22833e359, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jan 30 04:49:11 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283366, encodeId=4e3a28336643, content=非常好.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Tue Jan 30 04:10:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283335, encodeId=c607283335a9, content=很好的文章.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Mon Jan 29 23:32:06 CST 2018, time=2018-01-29, status=1, ipAttribution=)]
    2018-01-30 yjs木玉

    好好好好好好好好

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1819752, encodeId=85501819e52a5, content=<a href='/topic/show?id=6730998430a' target=_blank style='color:#2F92EE;'>#面部皮疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99843, encryptionId=6730998430a, topicName=面部皮疹)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad7f282, createdName=yang0210, createdTime=Tue Jun 12 02:46:00 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283467, encodeId=1b6628346e58, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Tue Jan 30 08:50:05 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283382, encodeId=6d4528338220, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue Jan 30 05:10:57 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283373, encodeId=0db22833e359, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jan 30 04:49:11 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283366, encodeId=4e3a28336643, content=非常好.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Tue Jan 30 04:10:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283335, encodeId=c607283335a9, content=很好的文章.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Mon Jan 29 23:32:06 CST 2018, time=2018-01-29, status=1, ipAttribution=)]
    2018-01-30 飛歌

    学习了很有用

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1819752, encodeId=85501819e52a5, content=<a href='/topic/show?id=6730998430a' target=_blank style='color:#2F92EE;'>#面部皮疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99843, encryptionId=6730998430a, topicName=面部皮疹)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad7f282, createdName=yang0210, createdTime=Tue Jun 12 02:46:00 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283467, encodeId=1b6628346e58, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Tue Jan 30 08:50:05 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283382, encodeId=6d4528338220, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue Jan 30 05:10:57 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283373, encodeId=0db22833e359, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jan 30 04:49:11 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283366, encodeId=4e3a28336643, content=非常好.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Tue Jan 30 04:10:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283335, encodeId=c607283335a9, content=很好的文章.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Mon Jan 29 23:32:06 CST 2018, time=2018-01-29, status=1, ipAttribution=)]
    2018-01-30 swfzhanggui

    非常好.谢谢分享

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1819752, encodeId=85501819e52a5, content=<a href='/topic/show?id=6730998430a' target=_blank style='color:#2F92EE;'>#面部皮疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99843, encryptionId=6730998430a, topicName=面部皮疹)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad7f282, createdName=yang0210, createdTime=Tue Jun 12 02:46:00 CST 2018, time=2018-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283467, encodeId=1b6628346e58, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Tue Jan 30 08:50:05 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283382, encodeId=6d4528338220, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Tue Jan 30 05:10:57 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283373, encodeId=0db22833e359, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=115, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Jan 30 04:49:11 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283366, encodeId=4e3a28336643, content=非常好.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Tue Jan 30 04:10:01 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=283335, encodeId=c607283335a9, content=很好的文章.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Mon Jan 29 23:32:06 CST 2018, time=2018-01-29, status=1, ipAttribution=)]
    2018-01-29 清风拂面

    很好的文章.谢谢分享

    0

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POD是心脏手术后术后虚弱的预测指标。术后虚弱和POD均与MACE发生率相关。

Diabetes Care:糖尿病与心脏手术后应激性高乳酸血症减少相关!

由此可见,应激性高乳酸血症在糖尿病患者中显著减弱。高乳酸血症、糖尿病、应激性高血糖之间存在相互作用,并且与心脏手术后的死亡率相关。

JAHA:心脏手术后的中期卒中风险

常规心脏手术后的30、60和90天的中期风险期,因缺血和出血性卒中的再入院率升高。

Circulation:心脏手术患者体外循环期间血压如何管理更利于预防脑损伤

脑损伤是体外循环(CPB)心脏手术术后的重要并发症,心脏手术后明显卒中发生率为1%~2%,弥散加权磁共振成像(DWI)可识别无症状性卒中发生率达50%。

Sci Rep:cfDNA与长时间体外循环心脏手术后的内皮损伤相关

这项研究证明在CPB持续时间长的心脏手术患者中,血浆cfDNA升高有助于评估CPB介导的不利影响。

JAHA:高密度脂蛋白胆固醇浓度与心脏手术后急性肾损伤相关!

由此可见,术前较高的高密度脂蛋白胆固醇与心脏手术后AKI的降低有关。术前和围手术期他汀类药物治疗增强了这种相关性。

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