外科手術部位感染的可控性因素

1、Modifiable Risk Factors for Surgical Site Infection手術部位感染的可控性風險因素手術部位感染的可控性風險因素 The Journal of Bone and Joint Surgery (American). 2011;93:398-404. Multiple risk factors for orthopaedic surgical site infection, have been identified： including a wide variety of demographic, comorbidity operative, and

2、postoperative variables, 目前已經(jīng)明確，骨科手術部位的感染包括多方面的風險因素，如各種不同的人群、合并癥、手術以及術后相關的因素等 The patient as a host is an important risk factor for infection, and many, if not most, patients are in suboptimal health. 患者作為宿主本身就是感染最重要的風險因素，即使不是大多數(shù)，那也有很多患者的健康狀況并不理想。 Optimizing the patients medical condition before sur

3、gery and eliminating or even diminishing modifiable risk factors for infection (Fig. 1) should lower the risk of surgical site infection. 在手術前將患者的內科情況調整到最佳狀態(tài)，杜絕或減少感染的可控性風險因素（圖1）應該可以降低手術部位感染的風險。 Direct scientific evidence showing that modification of these risk factors will lead to a decrease in surg

4、ical site infection is not readily available, and much work in this field remains to be done. 然而，對于控制這些風險因素便可減少手術部位感染的觀點，要找到直接的科學證據(jù)其實并不簡單，在這一領域仍有很多工作有待進一步深入。 It is imperative that surgeons have an extensive knowledge of modifiable risk factors affecting the wound-healing process and subsequent wound

5、 complications. 非常必要的是，外科醫(yī)生應該對影響創(chuàng)口愈合過程以及繼發(fā)創(chuàng)口并發(fā)癥的可控性風險因素有一個廣泛的認識。Modifiable Risk Factors for Surgical Site Infection and Possible Preoperative Interventions手術部位感染的可控性風險因素及可能的術前干預措施手術部位感染的可控性風險因素及可能的術前干預措施Rheumatoid Arthritis Patients with rheumatoid arthritis have an increased risk of infection follo

6、wing orthopaedic procedures. Patients with rheumatoid 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. 類風濕性關節(jié)炎 患有類風濕性關節(jié)炎的患者骨科手術后感染的風險明顯增加。 類風濕性關節(jié)炎類風濕性關節(jié)患者行全關節(jié)置換術后發(fā)生手術部位感染的風

7、險是骨關節(jié)炎患者的2-3倍。 Patients with rheumatoid arthritis are frequently being treated with complex 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. 類風濕性關節(jié)炎的患者常常要服用多種藥物，包括非甾體

8、類抗炎藥、皮質類固醇、氨甲喋呤及生物制劑等，所有這些都會對創(chuàng)口愈合以及感染的風險產(chǎn)生影響。 There are insufficient data from patients who have undergone orthopaedic procedures to make evidence-based recommendations about the majority of these medications. 目前對于大多數(shù)該類藥物而言，來自骨科手術患者的數(shù)據(jù)并尚不足以給出明確的循證醫(yī)學建議。 A good working relationship with the patients r

9、heumatologist is critical to making decisions about these medications. 應注意與患者的風濕科醫(yī)生保持密切的聯(lián)系，以決定這些藥物的應用方案。 Synthesis of the available data suggests the following. 綜合現(xiàn)有的數(shù)據(jù)可得出以下建議Nonsteroidal Anti-Inflammatory Drugs 非甾體類抗炎藥 While nonsteroidal anti-inflammatory drugs do not seem to increase transfusion r

10、equirements, morbidity, and mortality directly, they may increase intraoperative and postoperative bleeding. Increased bleeding may lead to a postoperative infection. 雖然非甾體類抗炎藥似乎并不會直接增加輸血的需求、致殘率及致死率， 但這些藥物可能會增加術中和術后的出血量。 出血增加可能導致術后感染。 Use of medications with short half-lives (ibuprofen and indometha

11、cin) should be discontinued one to two days before surgery. Use of drugs with 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. 半衰期較短的藥物（布洛芬和吲哚美辛）應在術前1-2天停藥

12、， 半衰期較長的藥物（萘普生）應在術前3天停藥， 而阿斯匹林應在術前7-10天停藥， 以便讓未受影響的血小板再生。 While cyclooxygenase-2 (COX-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

13、 are controversial with regard to the best way to handle these newer drugs. 雖然環(huán)氧化酶-2（COX-2）特異性抑制的非甾體類抗炎藥可能并不像非COX-2特異性抑制的非甾體類抗炎藥那樣與出血量密切相關， 還可能會影響骨愈合， 但關于應用這些新藥的最佳方案，相關的數(shù)據(jù)仍然存在爭議。Corticosteroids皮質類固醇 Inadequate doses of corticosteroids lead to disease flares and, in rare instances, adrenal insufficie

14、ncy. Corticosteroids have been shown to increase infection rates and affect wound-healing. In general, all patients on chronic corticosteroid therapy should receive their regular dose of corticosteroids perioperatively. 皮質類固醇的劑量應用不合理可導致疾病發(fā)作，并且在一些較為少見的情況下，還可能出現(xiàn)腎上腺功能不全。 有研究顯示皮質類固醇會增加感染率，影響創(chuàng)口愈合。 通常情況下，

15、所有長期接受皮質類固醇治療的患者在圍手術期仍應該按照標準劑量服用皮質類固醇。 The use of stress dose steroids remains controversial, and guidelines 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 be

16、en utilized, the anticipated stress level of the surgery, and the presence of other risk factors for infection. 應用大劑量的類固醇目前仍有爭議，指南也很難確立。 大劑量類固醇不應該作為常規(guī)來應用， 但應該根據(jù)應用某種類固醇的持續(xù)時間，可以預見的手術相關的應激水平，以及存在感染的其他風險因素等情況，進行個體化的處理。Methotrexate甲氨蝶呤 Most studies on the use of methotrexate perioperatively have not show

17、n an increased risk of infection. In general, use of methotrexate should not be discontinued perioperatively. 很多研究都顯示，術前應用甲氨蝶呤并不會增加感染的風險。 通常情況下，術前不停用甲氨蝶呤。 Patients with renal insufficiency (preoperatively or postoperatively), poorly controlled diabetes, lung or liver disease, or a history of alcohol

18、 abuse should discontinue using methotrexate preoperatively. This recommendation is especially important for patients undergoing high-stress procedures such as an arthroplasty or tumor resection. 如患者伴有腎功能不全（術前或術后），糖尿病控制不佳，肺或肝臟疾病，或者酗酒都應該在術前停用甲氨蝶呤。 如患者需要進行應激較大的手術，比如關節(jié)置換或腫瘤切除手術等，這一建議則尤為重要。Other Disease

19、-Modifying Antirheumatic Drugs其他緩解病情的抗風濕類藥物 Very little data are available to enable one to make recommendations about these medications。 Consultation with a rheumatologist preoperatively is highly recommended. 對于這一類藥物，幾乎沒有相關的數(shù)據(jù)可供參考。 對此，在術前請風濕科醫(yī)生會診則是非常明智的。 Biologics: Tumor-Necrosis-Factor (TNF) Anta

20、gonists and Interleukin-1 (IL-1) Antagonists生物制劑：腫瘤壞死因子（TNF）拮抗劑和白細胞介素-1（IL-1）拮抗劑 There are minimal data and experience on which to base strict recommendations about either of these classes of drugs. Serious infection is a known complication of TNF-inhibitor therapy. Perioperative use of such therapy

21、 has been shown to be safe in foot and ankle surgery. 對以上兩類藥物，目前相關的數(shù)據(jù)和經(jīng)驗都極為有限. 嚴重的感染是TNF拮抗劑治療的一個重要的并發(fā)癥。 有研究證明，在足踝外科手術的圍手術期應用這些藥物是安全的。 At this time, a conservative approach should be taken. For patients undergoing intensive procedures in particular, these medications should be withheld preoperatively

22、 for at least one dosing cycle and postoperatively until adequate wound-healing is observed. 此時，采取保守一些的方法還是比較可取的。 尤其對于手術較大的患者， 這些藥物應在術前停用至少一個療程， 并在術后創(chuàng)口愈合后再考慮續(xù)用。Human Immunodeficiency Virus (HIV)人類免疫缺陷病毒（HIV） The increased longevity of HIV-positive patients has created a new subset of potential candi

23、dates for total joint replacements and other orthopaedic procedures. Several retrospective reports, most involving small numbers of patients, have provided mixed results. 隨著HIV陽性患者的壽命不斷延長，在適合做全關節(jié)置換和其他骨科手術的患者人群中也增加了這樣一個亞組。 有幾項回顧性的病例報告，大多樣本量都較小，相關的結果差別也很大。 Whereas some studies showed an alarming rate

24、of postoperative infection in these patients, other studies did not. Prospective randomized studies on this topic are lacking. 有的研究顯示這些患者術后出現(xiàn)高的驚人的感染率，而另外一些研究的結果則并非如此。 對這一問題目前尚缺乏前瞻性的隨機研究。Diabetes Mellitus and Hyperglycemia糖尿病和高血糖 Diabetes has been associated with an increased risk of surgical site in

25、fection 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 more likely that the acute effects of perioperative hyperglycemia are even more detrimental. 在骨科的多個領域中，糖尿病都會增加手術部位感染的風險。 雖然，從某種程度上說，“

26、糖尿病的不利之處”可能與糖尿病所引起的病理改變有關， 然而，圍手術期急性的高血糖效應則可能更為不利 The increased risk of infection in diabetics undergoing orthopaedic surgery is often associated with complications related to wound-healing . To achieve appropriate wound-healing in diabetic patients, their nutritional status and insulin regimen must

27、 be optimized before they undergo any surgical procedure. 進行骨科手術的糖尿病患者感染的風險較高，這通常與創(chuàng)口愈合相關的并發(fā)癥有關（圖2）。 為了使糖尿病患者的創(chuàng)口能順利愈合，在進行任何手術之前，應該使其營養(yǎng)狀況和胰島素的用法都調整到最佳的狀態(tài)。Fig. 2 Infected wound dehiscence in a sixty-three-year-old woman with poorly controlled insulin-dependent diabetes who underwent a total knee replac

28、ement.圖2 女性，63歲，行全膝關節(jié)置換術，胰島素依賴型糖尿病控制不佳，創(chuàng)口感染開裂。 A recent study evaluating surgical site infection following orthopaedic spinal surgery identified hyperglycemia in patients not previously diagnosed with diabetes as a potential risk factor。 最近有一項評價骨科脊柱手術后的手術部位感染的研究，將既往未曾診斷為糖尿病的患者而出現(xiàn)高血糖視為一個潛在的危險因素。 Maln

29、utrition 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 who have gastrointestinal diseases, renal failure, alcoholism, cancer, or any chronic disease, should have their nutrit

30、ional status checked preoperatively.營養(yǎng)不良 大家知道，營養(yǎng)不良對于各種骨科手術的深部感染都是一個風險因素。 有些患者通常伴有營養(yǎng)不良的相關風險，如患有胃腸道疾病、腎功能不全、酗酒、癌癥或其他慢性病的老年患者。因此，術前應該對這些患者的營養(yǎng)狀況進行認真的檢查 A total lymphocyte count of 1500/mm3(1.5109/L), a serum albumin level of3.5 g/dL, or a transferrin level of 226mg/Dl has been associated with an increas

31、ed rate of wound complications. 有研究顯示，淋巴細胞總數(shù)1500/mm3（1.5109/L），血清白蛋白水平3.5g/dL，或轉鐵蛋白水平103/mL on urine culture 我們結合相關文獻，提出以下的一些建議： 做尿液分析和尿培養(yǎng)。 如有以下情況，應該考慮推遲手術，高風險患者尤其如此：術前評估顯示有尿道梗阻的相關癥狀?；颊哂信拍蚶щy和尿頻等癥狀，同時尿培養(yǎng)顯示尿菌落計數(shù)103/mL。Preoperative Anemia Some reports have indicated that post-operative anemia treated w

32、ith 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 transfusions is diminished. 術前貧血 有研究報告指出,同種異體輸血來治療術后貧血是手術部位感染的風險因素之一。 有幾項研究顯示，當術前貧血糾正后，術后外源性輸血的風險便可大大減少 Scre

33、ening for preoperative anemia and correcting the condition through the use of recombinant human erythropoietin (epoetin alfa) therapy has been studied in orthopaedic patients and has proven to be beneficial in some but not all instances. Epoetin alfa directly increases preoperative red-blood-cell ma

34、ss, hemoglobin concentration, and hematocrit levels. Even when a patient has chosen to donate autologous blood preoperatively, erythropoietin may be used as an adjunct。 對術前貧血進行篩查，并通過應用重組人紅細胞生成素（epoetin alfa，阿法依泊?。┻M行治療以糾正這種狀況，這一方法已有學者在骨科患者中進行過研究，結果證明，對有些病例但并不是所有病例都有效。 阿法依泊汀可直接增加術前血紅細胞總量、血紅蛋白濃度和紅細胞壓積水

35、平。 即便對選擇術前留取自體血的患者，也可輔助性地應用促紅細胞生成素。 Lastly, iron deficiency has been shown to be a common reason for failure of erythropoietin treatment, so iron levels need to be supplemented while the patient is being treated with recombinant erythropoietin. 最后，已有研究證實，鐵缺乏是導致促紅細胞生成素治療失敗的常見原因， 因此，對準備應用重組人紅細胞生成素進行治療

36、的患者，有必要適當補充鐵劑。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 the risk of an infection after the revision arthroplasty. 先前的手術會增加關節(jié)翻修手術后深部

37、感染的幾率。 如果初次關節(jié)置換手術后曾有感染的病史，則會使關節(jié)翻修手術后感染的風險增加。 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 these 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. 如果白細胞分類計數(shù)、紅細胞沉降率（ESR）和C反應蛋白（CRP）水平升高，應考慮潛在感染