胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理及其临床效果  

Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects

作　　者：张万福 徐婧 张敬群[2] 韩飞 佟琳 张浩 官浩 Zhang Wanfu;Xu Jing;Zhang Jingqun;Han Fei;Tong Lin;Zhang Hao;Guan Hao(Department of Burns and Cutaneous Surgery,Burn Center of PLA,the First Affiliated Hospital,Air Force Medical University,Xi'an 710032,China;Department of Burns and Plastic Surgery,Affiliated Hospital of Jining Medical College,Jining 272100,China)

机构地区：[1]空军军医大学第一附属医院全军烧伤中心,烧伤与皮肤外科,西安710032 [2]济宁医学院附属医院烧伤整形科,济宁272100

出　　处：《中华烧伤与创面修复杂志》2024年第2期151-158,共8页Chinese Journal of Burns And Wounds

基　　金：国家自然科学基金面上项目(82272268);教育部中国高校产学研创新基金(2021JH030)。

摘　　要：目的探讨胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理方式,并评价其临床效果。方法该研究为回顾性观察性研究。2017年1月—2022年12月,空军军医大学第一附属医院全军烧伤中心收治36例符合入选标准的胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面患者,其中男23例、女13例,年龄25~81岁。做好手术相关准备,对于疑有胸骨后纵隔脓腔的患者,咬除未愈合胸骨全部松质骨,充分暴露胸骨后纵隔,清除感染源及肉芽组织,采用单侧胸大肌翻转填塞胸骨缺损;对于确无胸骨后纵隔感染且胸骨未愈合创面肉芽组织新鲜的患者,姑息性清除坏死组织及少量坏死胸骨,采用双侧胸大肌推进对接覆盖胸骨缺损。将供区皮肤减张缝合后行持续负压封闭引流,24 h后开始加行持续均匀滴注灌洗。用盔甲式胸带固定胸廓,引导患者腹式呼吸,同时用外科约束带固定双上肢于侧胸壁。记录入院时创面分泌物标本细菌培养结果。记录术中观察的创面情况,术中出血量,术后滴注灌洗天数、每日灌洗液体量,术后并发症发生情况及创面愈合耗时。出院后随访,评估创面愈合质量、胸廓外形、胸廓和双上肢活动功能;复查CT,观察胸骨稳定性及闭合情况。结果入院时,36例患者创面分泌物标本细菌培养结果中33例为阳性,3例为阴性。术中观察显示,确无胸骨后纵隔感染且胸骨未愈合创面肉芽组织新鲜的患者26例,疑似有胸骨后纵隔脓腔患者10例。术中,1例患者在接受纵隔探查时无名静脉破裂出血约3000 mL,其余患者出血量为100~1000 mL。术后滴注灌洗4~7 d,灌洗液体量为3500~4500 mL/d。除因于术后3 d护理中从腋窝处搬移1例患者致该患者缝合口裂开外,其余患者创面术后均顺利愈合;所有患者创面愈合耗时为7~21 d。出院后随访3~9个月显示,前述从腋窝处搬运致缝合口裂开的1例患者因多器官功Objective To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy,and to evaluate its clinical effects.Methods This study was a retrospective observational study.From January 2017 to December 2022,36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University,including 23 males and 13 females,aged 25 to 81 years.Preparation for surgery was made.For patients with suspected retrosternal mediastinal abscess cavity,all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum,remove the source of infection and granulation tissue,and to fill the sternum defect with flipped unilateral pectoralis major muscle.For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds,the necrotic tissue and a small amount of necrotic sternum were palliatively removed,and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect.After the skin in the donor area was closed by tension-relieving suture,continuous vacuum sealing drainage was performed,and continuous even infusion and lavage were added 24 hours later.The thorax was fixed with an armor-like chest strap,the patients were guided to breathe abdominally,with both upper limbs fixed to the lateral chest wall using a surgical restraint strap.The bacterial culture results of wound exudation specimens on admission were recorded.The wound condition observed during operation,debridement method,muscle flap covering method,intraoperative bleeding volume,days of postoperative infusion and lavage,lavage solution volume and changes on each day,and postoperative complications and wound healing time were recorded.After discharge,the wound healing quality,thorax shape,and mobility function

关 键 词：胸骨 骨髓炎 围手术期医护 外科皮瓣 组织固定 纵隔炎 精准清创 滴注灌洗 

分 类 号：R687.3[医药卫生—骨科学]