临床小儿外科杂志  2020, Vol. 19 Issue (9): 806-809  DOI: 10.3969/j.issn.1671-6353.2020.09.009

引用本文  

林野, 李守军. 封闭式持续负压吸引治疗小儿心脏外科手术后累及胸骨的深部切口感染[J]. 临床小儿外科杂志, 2020, 19(9): 806-809.
Lin Y, Li SJ. Clinical outcomes of vacuum-assisted closure for deep sternal wound infection after pediatric cardiac surgery[J]. Journal of Clinical Pediatric Surgery, 2020, 19(9): 806-809.

基金项目

十三五国家重点研发计划(编号:2017YFC1308100)

通讯作者

李守军, Email:drlishoujunfw@163.com

文章历史

收稿日期:2020-05-10
封闭式持续负压吸引治疗小儿心脏外科手术后累及胸骨的深部切口感染
林野 , 李守军     
中国医学科学院, 北京协和医学院, 国家心血管病中心, 心血管疾病国家重点实验室, 阜外心血管病医院小儿心脏外科中心(北京市, 100037)
摘要目的 对使用封闭式持续负压吸引(vacuum-assisted closure,VAC)治疗小儿心脏外科手术后累及胸骨深部切口感染(deep sternal wound infection,DSWI)的临床经验进行总结。方法 2017年2月至2020年2月,中国医学科学院阜外心血管病医院小儿心脏外科中心共收治6例年龄小于7岁的经胸骨正中切口手术后发生DSWI的患者,均接受封闭式持续负压吸引治疗。其中男4例,女2例;年龄15天至5岁,平均(2.18±1.85)岁;体质量3~19 kg,平均(10.43±5.96)kg。患儿切口感染均累及胸骨或纵膈组织,伤口裂开同时伴有不同程度的胸骨切割或纵膈感染,均需入手术室行清创手术。患儿基础心脏疾病包括:完全型大动脉转位1例,法洛四联症2例,右室双出口1例,室间隔缺损1例,完全型肺静脉异位引流1例;伤口分泌物培养阳性3例(金黄色葡萄球菌1例,表皮葡萄球菌2例)。选择VAC治疗的原因为:伤口感染严重、渗出量多或者患儿依从性差无法耐受床旁换药。本组6例分别于术后第7~20天给予封闭式负压吸引治疗。方法如下:开放原手术切口直至充分显露胸骨,彻底清除切口内的坏死组织,修剪出与切口大小一致的黑色泡沫敷料填充于胸骨表面,最后用贴膜密闭创口,于渗出较多处开口,接负压吸引装置,初始压力为50 mmHg,治疗模式为持续吸引,吸引强度为轻到中级强度,年龄5岁以上患儿如果渗出较多,可以将压力增加至75 mmHg,观察每日伤口引流量及颜色,待引流液少于10 mL/d、引流液颜色变淡呈浆液性,无脓性分泌物,肉芽新鲜后入手术室行清创缝合术,术后定期观察伤口。结果 6例中无一例住院期间死亡。使用VAC治疗时间为5~7 d,在使用VAC治疗后伤口渗液明显减少,颜色变淡;患儿体温下降,血白细胞计数逐渐恢复正常,6例均在完成一个VAC治疗周期后进手术室接受清创手术,其中5例顺利保留胸骨并完成了二期清创缝合手术,另外1例由于发现感染的时间晚,胸骨坏死严重,在清创手术后感染复发,又进行了二次清创手术,同期行胸大肌肌瓣转移手术。6例均痊愈出院,在使用VAC治疗过程中未出现活动性出血、循环波动等并发症,患儿均未主诉伤口疼痛。结论 封闭式持续负压吸引治疗小儿心脏外科胸骨正中切口术后累及胸骨深部的切口感染安全有效,值得推广应用。
关键词胸骨正中切口    切口感染    封闭式持续负压吸引    
Clinical outcomes of vacuum-assisted closure for deep sternal wound infection after pediatric cardiac surgery
Lin Ye , Li Shoujun     
Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences&Peking Union Medical College, Beijing 100037, China
Abstract: Objective To retrospectively evaluate the clinical outcomes of vacuum-assisted closure (VAC) for deep sternal wound infection (DSWI) after pediatric cardiac surgery. Methods From February 2017 to February 2020, 6 DSWI children aged under 7 years after median sternotomy underwent VAC.There were 4 boys and 2 girls with an average age of (2.18±1.85) years (15 days to 5 years) and an average body weight of (10.43±5.96)(3-19) kg.The underlying cardiac diseases included complete transposition of the great arteries (n=1), tetralogy of Fallot (n=2), double outlet of right ventricle (n=1), ventricular septal defect (n=1), TAPVC (n=1), 1 case of neonatal patient, wound secretion culture positive (n=3)[including Staphylococcus aureus (n=1) and Staphylococcus epidermidis (n=2)].The reasons for selecting VAC were severe wound infection, excessive exudation, or poor compliance of not tolerating bedside dressing changes.Six cases underwent VAC at Day 7-20 post-operation.The specific procedure was as follows:opening original surgical incision until a full exposure of sternum, completely removing necrotic tissue, trimming a black foam dressing of the same size as incision, filling the surface of sternum and finally sealing wound with a film.The initial pressure was 50 mmHg.The treatment mode was continuous suction with a light-to-medium strength.For children aged over 5 years with massive, the pressure might be elevated to 75 mmHg.Daily volume and color of wound drainage were recorded.After the daily volume of drainage fluid became < 10 ml, color turned serous and non-purulent and granulation was fresh.Wound debridement and suturing were performed and regular postoperative observations followed. Results None of them died during hospitalization.After a course of VAC for 5-7 days, wound exudate decreased markedly, color became pale, body temperature declined and white blood cell count gradually normalized.Six cases returned to operating room for wound debridement.In 5 cases, a second debridement was successful and sternum preserved.In another case, due to late infection time and severe sternal necrosis, infection recurred after debridement and debridement was repeated with major muscle flap transfer.All 6 children were cured and discharged.During VAC, there were no complications such as active bleeding or circulatory fluctuation.There was no complaint of wound pain. Conclusion VAC is both safe and effective for deep sternal wound infection after median sternotomy after pediatric cardiac surgery.
Key words: Median Sternotomy    Wound Infection    Vacuum-assisted Closure Therapy    

心脏外科手术后累及胸骨的深部切口感染(deep sternal wound infection,DSWI)是一种少见但严重的手术并发症,发病率为0.25% ~2.8%[1-3]。一旦发生会导致患者住院时间及住院费用显著增加,成年患者病死率可达10% ~47%[4-7]。随着近年来小儿心脏外科的不断发展,接受心脏手术的低龄、低体质量及重症患儿逐年增多;受手术时间长、呼吸机辅助及ICU时间延长等因素的影响,术后伤口感染发生率开始增多。但是临床上对累及胸骨的深部切口感染的治疗方法并不统一,治疗效果千差万别[8]。传统换药及清创手术患儿依从性差,失败率较高,目前国际上公认效果较好的治疗方法为封闭式持续负压吸引(vacuum-assisted closure,VAC),文献报道,与传统清创手术相比,封闭式持续负压吸引治疗可以降低患者死亡率及并发症发生率[9]。然而VAC负压吸引用于治疗小儿深部切口感染的文献报告罕见,其是否能用于小儿复杂先心病或者新生儿患者目前仍不明确。本文总结了我院2017年2月至2020年2月之间6例应用封闭式持续负压吸引治疗的心脏外科胸骨正中切口手术后DSWI的临床经验,现报告如下:

材料与方法 一 一般资料

2017年1月至2020年2月,中国医学科学院阜外心血管病医院小儿心脏外科中心共有12例经胸骨正中切口行心脏手术患儿发生了累及胸骨的深部切口感染,年龄均小于7岁;12例DSWI患儿中,有6例接受了封闭式持续负压吸引治疗。其中男4例,女2例;年龄15天至5岁,平均年龄(2.18±1.85)岁;体质量3~19 kg,平均体质量(10.43±5.96)kg。本文入选病例排除了感染只累及皮肤及皮下组织的表浅伤口感染患儿,6例感染均累及胸骨或者纵膈组织,伤口裂开的同时伴有不同程度的胸骨切割或纵膈感染,均需行清创手术。患儿基础心脏疾病包括:完全型大动脉转位1例,法洛四联症2例,右室双出口1例,室间隔缺损1例,完全型肺静脉异位引流1例,新生儿患者1例,伤口分泌物培养阳性3例(包括金黄色葡萄球菌1例,表皮葡萄球菌2例)。

二 治疗方法

所有患儿确诊DSWI后即开放原手术切口,床旁纱条换药引流,同时经静脉给予广谱抗生素治疗。本组6例选择VAC治疗的原因为患儿伤口感染严重、渗出液量多或者患儿依从性差无法耐受床旁换药,分别于术后第7~20天给予封闭式负压吸引治疗。负压吸引装置的使用方法如下:完全开放原手术切口直至充分显露胸骨,拆除所有皮肤及皮下组织缝线,彻底清除切口内的坏死组织,一般保留原胸骨固定缝线(图 1A),修剪出与切口大小一致的黑色泡沫敷料填充于胸骨表面(图 1B),由于多数患儿胸骨松动,故可以将部分黑色泡沫敷料填充进胸骨中间,对胸骨上窝和剑突下也用小块黑色泡沫敷料填充,以利于胸骨后渗液的引流,最后用贴膜密闭创口,于渗出较多处开口接负压吸引装置(图 1C),初始压力为50 mmHg,治疗模式为持续吸引,吸引强度为轻到中级;年龄5岁以上患儿如果渗出较多,可以将压力增加至75 mmHg,观察每日伤口引流量及颜色,待引流液少于10 mL/d,引流液颜色变淡呈浆液性,无脓性分泌物,肉芽新鲜后进入手术室行清创缝合术。清创手术方法:清除皮肤及皮下坏死组织,游离胸骨后粘连,仔细探查纵隔及清创后重新固定胸骨并留置纵隔引流管;对皮肤及皮下组织间断缝合,术中尽可能清除坏死组织,同时恢复胸骨的稳定,对合并胸骨切割的患者采用跨肋间固定胸骨;如果探查发现胸骨坏死严重或者清创手术失败后无法保留胸骨的患者,行胸大肌肌瓣转移术,术后定期观察伤口。


图 1 经胸骨正中切口行心脏手术患儿术中图片 Fig.1 Intraoperative pictures of children undergoing cardiac surgery through a median sternum incision  A:完全开放原手术切口直至充分显露胸骨,拆除所有皮肤及皮下组织缝线,彻底清除切口内的坏死组织,保留原胸骨固定缝线; B:修剪出与切口大小一致的黑色泡沫敷料, 填充进松动的胸骨中间,胸骨上窝和剑突下也用小块黑色泡沫敷料填充,以利于胸骨后渗液的引流; C:用两层贴膜密闭创口,于渗出较多处开口接负压吸引装置
结果

6例中无一例住院死亡,使用VAC的治疗时间为5~7 d,在使用VAC治疗后伤口渗液明显减少,颜色变淡;患儿体温下降,血白细胞计数逐渐恢复正常。6例均在完成一个VAC治疗周期后接受清创手术,清创过程中发现患儿伤口创面比VAC使用前明显干净清洁,伤口局部残余感染灶及坏死组织面积减少,清创手术难度降低,清创范围减小,其中5例顺利保留胸骨并完成了二期清创缝合手术;另外1例由于发现感染时间晚,胸骨坏死严重,在清创手术后感染复发又进行了二次清创手术,行胸大肌肌瓣转移手术,6例均痊愈出院,在使用VAC治疗过程中未出现活动出血、循环波动等并发症,患儿未诉伤口疼痛。

讨论

心脏外科手术后伤口感染包括表浅伤口感染和累及胸骨的深部切口感染。表浅感染累及皮肤及皮下脂肪组织,发生率为0.5% ~8%,通过及时清创引流结合抗生素治疗,常可迅速愈合[10, 11]。而累及胸骨的深部切口感染是一种严重的手术并发症,临床诊断依据包括胸骨松动,随咳嗽和深呼吸有液体自胸骨切口渗出,胸骨或纵膈渗液细菌培养阳性,临床表现有发热、切口疼痛、白细胞升高等[12]。由于累及胸骨的深部切口感染死亡率及并发症发生率高,临床上需要采取更加积极的治疗策略,尽早发现、确诊后彻底引流,尽早行清创手术并延长抗生素使用时间。

小儿心脏外科手术后发生累及胸骨深部切口感染的危险因素与成人患者不同,成人患者多合并糖尿病,此外冠状动脉旁路移植手术中获取乳内动脉导致的胸骨血运不足等原因也可导致患者术后容易发生累及胸骨的深部切口感染;而小儿外科手术后发生DSWI的主要危险因素包括低龄、复杂紫绀先心病、延迟关胸、手术时间长、呼吸机时间及ICU时间长、术前合并感染等[13, 14]

DSWI的外科治疗方法目前仍不统一,传统的换药及清创手术有较高的失败率及死亡率。国际上公认效果较好的治疗方法为VAC负压吸引治疗,文献报道与传统清创手术相比,VAC负压吸引治疗可以降低患者死亡率及并发症发生率[8, 9]。然而VAC负压吸引在小儿患者中的治疗经验在文献报告中罕见,其是否能用于小儿复杂先心病或者新生儿患者目前仍不明确,通过本组6例患者的治疗经验我们发现,与传统纱布条引流换药相比,VAC负压吸引治疗具有以下优点:①减少伤口换药次数,传统换药方式需要每天换药2~3次,渗出多的患者换药次数更多,患者非常痛苦,同时也增加了伤口暴露引起的感染加重及扩散,尤其在小儿患者中,进行床旁换药患儿的依从性差,难以做到彻底清创及充分引流;而VAC负压吸引治疗可以每5~7天更换一次敷料,治疗过程中不影响患者日常活动,而且引流更彻底,减轻了患者痛苦,避免了开放引流换药导致的感染扩散。②VAC负压吸引治疗能够促进肉芽组织生成,稳定胸骨,并且能够减轻组织水肿,抑制细菌繁殖,缩小创口,增加清创手术成功率,降低死亡率,避免了反复清创给患者带来的痛苦,并且保留胸骨。另外,本组患儿年龄跨度从15天到5岁,在使用VAC治疗过程中没有出现出血、循环波动等并发症,患儿无疼痛等不适主诉,说明该治疗方法在小儿患者中是安全有效的,对于重症累及胸骨的深部切口感染患者,我们也推荐使用VAC封闭式负压吸引治疗[8]

总之,封闭式持续负压吸引治疗小儿心脏外科胸骨正中切口手术后累及胸骨的深部切口感染是安全有效的,值得推广应用。

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