化脓性链球菌致急性感染性暴发性紫癜合并脓毒性休克老年患者的救治实践  

Management of elderly patients with acute infectious fulminant purpura and septic shock caused by Streptococcus pyogenes

作　　者：何宗钊[1] 孙斌[1] 马四清[1] 郭利涛 王皓[1] He Zongzhao;Sun Bin;Ma Siqing;Guo Litao;Wang Hao(Department of Critical Care Medicine,Qinghai Provincial People's Hospital,Xining 810007,Qinghai,China;Department of Critical Care Medicine,the First Afiliated Hospital of Xian Jiaotong University,Xi'an 710061,Shaanxi,China)

机构地区：[1]青海省人民医院重症医学科,青海西宁810007 [2]西安交通大学附属第一医院重症医学科,陕西西安710061

出　　处：《中国中西医结合急救杂志》2024年第1期95-99,共5页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：青海省卫生计生系统指导性计划课题(2020-wjzdx-03);青海省“昆仑英才·高层次卫生健康人才”项目(2023-10)。

摘　　要：目的观察化脓性链球菌(GAS)致急性感染性暴发性紫癜(AIPF)并脓毒性休克老年患者的临床表现,分析指标变化及救治过程,为此类疾病的诊断和治疗提供临床参考。方法回顾性分析青海省人民医院重症医学科2021年6月17日救治的1例GAS致AIPF合并脓毒性休克老年患者的病例资料、临床表现、体征、检查指标及救治过程;结合既往文献报告的相关内容,探讨该类疾病的病理生理特征和救治措施,并观察患者预后。结果患者男性,80岁,既往体健,1年前接受膝关节手术,2021年6月17日因“左侧面部疼痛肿胀伴张口困难2d”入院。入院后完善实验室血常规、血生化和凝血功能检查,头颅CT示左侧咬肌肿胀,面颊部皮下渗出,左侧咽旁间隙显示不清,咽鼓管开口显示欠佳,咽喉部狭窄;彩色超声示左侧颌面部及眼脸软组织肿胀,间隙内水肿。入院6+h,患者右侧面、颈、肩及胸上部逐渐出现紫斑、血疤和坏死,伴触痛、高热,以颜面部为主;心率波动在150次/min左右,血压108/71mmHg(1mmHg~0.133kPa,间羟胺6.67μg·kg^(-1)·min^(-1)维持血压),诊断为脓毒性休克,转至重症监护病房(ICU)抢救治疗。在及时有效综合监测下给予维持呼吸循环稳定为基础的积极救治,经血浆输注,早期创面处理,合理及时抗感染及炎症因子清除,器官功能保护和支持治疗,最终患者好转出院,随访6个月未复发。结论GAS急性感染起病急且危重,病情进展快,病死率高,救治难度极大;但及时有效的精细化综合监测、评估及治疗仍能取得良好的救治效果。Objective To observe the clinical manifestations of elderly patients with acute infectious purpura fulminant(AIPF)and septic shock caused by Streptococcus pyogenes(GAS),analyze the changes in indicators and treatment processes,and provide clinical references for the diagnosis and treatment of such diseases.Methods A retrospective analysis was conducted on the case data,clinical manifestations,signs,examination indexes and treatment process of an elderly patient who presented with GAS-induced AIPF combined with septic shock and was treated by the department of critical care medicine of Qinghai Provincial People's Hospital on June 17th,2021.This study also involved a discussion on the pathophysiological characteristics and treatment measures for these diseases as well as observation of patient prognosis.Results The 80-year-old male patient,who was previously in good health,underwent knee surgery one year ago and was admitted to the hospital on June 17,2021 due to"pain and swelling of the left face with difficulty opening the mouth for the past 2 days".Upon admission,a complete set of laboratory tests including blood routine,blood biochemistry and coagulation function were conducted.A head CT revealed swelling of the masseter muscle on the left side,subcutaneous exudation of the cheek,non-cyanotic space on the left parapharyngeal space,poor display of eustachian tube opening,and narrow throat.Color ultrasound showed soft tissue swelling and interstitial edema in the left maxillofacial region and eyelid.Six hours after admission,the patient gradually developed purple spots,blood scars and necrosis on the right side neck shoulder and upper chest accompanied by tenderness and high fever mainly on his face.The heart rate fluctuated around 150 times per minute while blood pressure was at 108/71 mmHg(1 mmHg~0.133 kPa,Metaraminol 6.67μg·kg^(-1)·min^(-1)).The patient was diagnosed with septic shock and transferred to intensive care unit(ICU)for emergency treatment.With timely comprehensive monitoring in place,the patient

关 键 词：化脓性链球菌 急性感染 暴发性紫癜 脓毒症 救治 

分 类 号：R459.7[医药卫生—急诊医学]