严重腹腔感染的外科救援策略与技术  

Surgical rescue strategies and techniques for severe intra-abdominal infection

作　　者：任建安 Ren Jian'an(Research Institute of General Surgery,Affiliated Jinling Hospital,Medical School of Nanjing University,Nanjing 210002,China)

机构地区：[1]东部战区总医院、全军普通外科研究所、南京大学医学院附属金陵医院,南京210002

出　　处：《中华胃肠外科杂志》2023年第9期813-817,共5页Chinese Journal of Gastrointestinal Surgery

基　　金：国家自然科学基金(82270595);江苏省重点研发计划(BE2022823);江苏省医学创新中心(CXZX202217)。

摘　　要：严重腹腔感染是指合并有脓毒症或脓毒性休克的腹腔感染,亦称腹腔脓毒症。手术后并发症、创伤和急腹症均可引起严重腹腔感染,外科救援是指腹腔感染发生后所采取的一系列急救措施。导致外科救援失败的机构因素包括医院规模、高新技术、外科医生和护理人员素质。导致外科救援失败的患者因素有高龄、糖尿病和急慢性脏器功能障碍。指导腹腔感染外科救援的策略包括损伤控制外科理论和损伤控制性复苏策略。应根据感染严重度,尽快采取由小到大逐渐升级的感染源控制措施。这些措施依次为去除血管内导管、更换腹腔引流管、腹腔穿刺器辅助的经皮脓肿穿刺引流、剖腹引流术和腹腔开放疗法。由于严重腹腔感染的致病菌多为表达耐碳青霉烯酶的多重耐药菌,故可在细菌药敏结果出来前,通过快速鉴定碳青霉烯酶型,提前指导经验性抗生素的选择,即"先酶后菌"的抗生素选择策略。Severe intra-abdominal infection is complicated with sepsis or septic shock and could also be named as intra-abdominal sepsis.Surgical rescue is an effective intervention for severe intra-abdominal infection,which can be caused by surgery,trauma or acute abdomen.Institutional factors associated with failure of surgical rescue include hospital volume,technology,surgeons and nurses.Patient factors contributing to failure include advanced age,diabetes mellitus and chronic organ dysfunction.The surgical rescue strategy for severe intra-abdominal infection includes damage control surgery and damage control resuscitation.Stepwise escalated procedures based on the severity of the infections should be performed as soon as possible to control the infection source,including removal of catheter in blood vessel,change of intra-abdominal drainage,trochar-assisted percutaneous abscess drainage(TA-PAD),laparotomy and open abdomen therapy.Since most of the pathogenic microorganisms of severe abdominal infections are multi-drug resistant bacteria expressing Klebsiella pneumoniae carbapenemase(KPC),the choice of empirical antibiotics can be guided by rapid identification of the KPC type before the results of antibiotic susceptibility testing are available,namely the antibiotic selection strategy of"enzyme first,then bacteria".

关 键 词：腹腔感染 脓毒症 外科救援 感染源控制 复苏 

分 类 号：R619.3[医药卫生—外科学]