严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例.doc

严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例 A Case of Cerebral Multiple Abscess Occuring With Deep Vein Catheter Related Infection After Severely Burnt 患者男，36岁，因全身火焰烧伤于伤后3h入院。入院时检查: T36.1℃, P96次/min, R 22次/min, 患者一般情况可，神志清楚，呼吸平顺，烧伤创面分布于头面、颈，躯干及四肢，创面基底大部分呈黄白色。入院诊断: ①烧伤总面积35% , 浅II度15%,深II度20%。入院后行右侧股静脉穿刺置管常规液体复苏、创面清创，头面部暴露,四肢及躯干创面外用1%磺胺嘧啶银霜包扎等治疗。入院后20h,患者面颈部、双前臂肿胀明显,自诉喉头有异物感及双手指麻木等不适,遂于局麻下行气管切开,双上肢烧伤皮肤及浅筋膜切开减压术,随后病情平稳。伤后5d在静脉全麻下行“双上肢、左小腿深II度创面15%削痂、自体网状皮移植术”，术后应用头孢哌酮+依替米星抗感染,面部深II度创面,躯干等部位创面继续外用1%磺胺嘧啶银霜隔日换药,创面分泌物未培养出细菌,术后5d,削痂植皮创面换药,皮片成活良好，伤后14d拔除气管套管，拔管后患者呼吸平顺，病情稳定，除右下腹及左足背约1%深II度创面未愈外,其余创面均愈合。治疗过程中,伤后11d开始,患者出现高热,最高达40.1℃,外周血白细胞计数达20.1×109/L,中心粒76%,调整抗生素为美洛西林+依替米星二联抗感染,2d后, 外周血白细胞计数下降至11.4×109/L, 中心粒细胞86%,体温仍有波动,最高为38.9℃, 胸部X-线检查未见双肺有异常改变。伤后15d再次出现寒战、高热，考虑有金黄色葡萄球菌感染可能,拔除右侧股静脉导管并送细菌培养, 调整抗菌素为稳可信500mgq6h静脉点滴, 再次送检创面分泌物细菌培养及血培养。3d后,静脉导管、创面分泌物及血细菌培养均为耐甲氧西林金黄色葡萄球菌生长（MRSA），体外药物敏感试验对万古酶素敏感，继续静滴稳可信,患者体温有所下降，但渐渐出现神情淡漠、懒言及肢体乏力等症状, 静滴稳可信6d后，出现左上肢肌力减退（III级），行颅脑MR检查示：右侧小脑半球及颞叶、额叶见多发片状长T1、T2信号影，境界模糊，压水序列像上呈高信号，增强扫描见明显环行强化或不完全的环形强化，局部脑沟、裂变窄，最大病灶位于右侧颞叶，大小约3cm×2.8cm，两侧大脑，左侧小脑尚可见散在小斑点样强化灶。提示两侧大脑、小脑多发性感染灶，部分脓肿形成，结合临床诊断为烧伤后颅内多发性MRSA感染，部分脓肿形成。转神经内科继续稳可信并加用磷霉素钠抗感染，甘露醇脱水降颅压等治疗，一周后，因脓肿破裂出血死亡。 译文： The patient, male, 36 years old, was sent to hospital 3 hours after he was burnt by flame all over his body.Examination on admission: 36.1T℃, P96 times/min, R 22 times/min, patient was in ordinary condition with conscious mind and smooth breath. The burnt wound spreads in head, neck, body and 4 limbs.The base of burnt wound was mostly yellowish white.Diagnosis on admission: ①Total burnt area 35%, II degree superficial burn 15%, II degree deep burn 20%. After admission, the patient received treatment of indwelling catheter by right femoral vein puncture conventional fluid resuscitation, wound debridement, head and face exposure, 4 limbs and body wound bound up externally with 1% density sulfadiazine silver frost, etc. 20 hours after admission, patient’s face, neck and both forearms were obviously swelling. He complained there was malaise feeling of foreign-body sensation in throat and numbness in both hands fingers. So tracheotomy, burnt skin of both arms and superficial fascia incision release were carried out. Then the patient’s condition was improving. 5 days after injury, 15% of both arms, left calf II degree deep burnt wound scab excision and meshed autogenous skin transplantation were carried out under intravenous anaesthesia. After operation, cefoperazone and etimicin were used to prevent infection, and 1% density sulfadiazine silver frost was still applied externally in II degree deep burnt face wound and body wound which would be refreshed on alternate days. Bacteria was not cultured from wound secretion. 5 days after operation, medicine was refreshed for scab excision and skin grafting wound.The skin graft flap was well developed. 14 days after injury trachea cannulas was pulled off and the patient could breathe smoothly and condition was stable. All wound areas were healed except 1% of II degree deep burnt wound in right lower abdomen and left dorsalis pedis.During treatment, since 11 days after injury, patient was found have high fever, and the highest temperature could reach 40.1℃,the number of peripherial leucocytes amounted to 20.1×109/L with centriole 76%. The adjusting antibiotic was 2-drug mezlocillin and etimicin anti-infective. 2 days later, the number of peripherial leucocyte dropped to 11.4×109/L with centriole 86%. Body temperature of patient still had fluctuation and the highest temperature reached 38.9℃. Chest X-ray inspection found no abnormal changes in both lungs.15 days after injury, patient was found have again shivering and high fever. Considering there was possibility of staphylococcus aureus infection, the right femoral vein catheter was pulled off and usd for bacteria culture, antibiotic was adjusted into vincocin 500mgq6h intravenous infusion, and the wound secretion was used again for bacteria culture and blood culture.3 days later, vein catheter, wound secretion and blood bacteria culture were all methicillin resistant staphylococcus aureus grow (MRSA), being sensitive to vancomycin through vitro drug sensitivity test. Continue to intravenously drippinginject with vancomycin, patient body temperature dropped to some extent, but gradually appeared symptoms of looking indifference, lazy speaking, and limbs weakness. After 6 days of intravenous infusion of vancomycin, left upper extremity muscle strength weakness was found ( degree III). Craniocerebral inspection was made and indicated: there were multiple flake style T1, T2 signal density with obscure realm in right cerebella hemisphere, temporal lobe and front lobe. Pressurized water sequence image showed high signal, enhanced scan showed evident ring enhancement or incomplete enhancement, and partial cerebral sulcus and cerebral fissure got narrowed. The biggest focus lied in right temporal lobe and the size was about 3cm×2.8cm, and there were still seperat