妇产科围手术期脓毒症的临床分析
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摘要
目的:分析妇产科围手术期脓毒症的病例特点,为脓毒症的防治提供依据。方法:收集首都医科大学附属北京妇产医院2011年1月—2017年12月诊断为脓毒症的病例14例,分析其病例特点,并根据病原学分为G~-杆菌组及G~+球菌组(真菌感染患者仅有1例,未作统计学分析),对比组间差异。结果:妇产科围手术期脓毒症的病原体多为G~-杆菌,占71.4%,脓毒症患者血白细胞计数、C反应蛋白水平、降钙素原水平均较正常参考值显著升高,G~-杆菌组纤维蛋白原(FIB)较G~+球菌组显著减低(P=0.045),G~-杆菌组国际标准化比值(INR)(P=0.043)及D-二聚体(D-D)(P=0.039)较G~+球菌组显著升高,差异均有统计学意义。5例脓毒性休克患者均为G~-杆菌感染。结论:妇产科围手术期脓毒症以G~-杆菌感染为主,炎症反应强烈,同时伴随严重的凝血功能异常,易发生脓毒性休克,及早发现、经验性抗感染治疗及早期应用低分子肝素预防弥散性血管内凝血(DIC)对改善预后至关重要。
Objective:To analyze the characteristics of perioperative sepsis in obstetrics and gynecology, and to provide evidence for the prevention and treatment of sepsis. Methods: The cases of sepsis diagnosed in Beijing Obstetrics and Gynecology Hospital from January 2011 to December 2017 were collected. The characteristics of the cases were analyzed.According to the pathogens, the differences between the G~- bacteria group and the G~+ cocci group were compared. Results: The pathogens of perioperative sepsis in gynecology and obstetrics were mostly G~- bacteria, accounting for 71.4%. The white blood cell count, C-reactive protein level and procalcitonin level were significantly increased in patients with sepsis. The fibrinogen(FIB) of the G~- bacteria group was significantly lower than that of the G~+ cocci group(P=0.045). The international normalized ratio(INR) of the G~- bacteria group(P=0.043) and the D-dimer(DD)(P=0.039) was significantly higher than the G~+ cocci group.The differences were statistically significant. 5 patients with septic shock were all G~- bacteria infection. Conclusions:Perioperative sepsis in obstetrics and gynecology is mainly caused by G~- bacteria infection.This type of sepsis has a strong inflammatory response, severe coagulopathy, and septic shock tendency. Early detection, empirical anti-infective therapy, and early application of low molecular weight heparin to prevent disseminated intravascular coagulation(DIC) are critical for improving prognosis.
Objective:To analyze the characteristics of perioperative sepsis in obstetrics and gynecology, and to provide evidence for the prevention and treatment of sepsis. Methods: The cases of sepsis diagnosed in Beijing Obstetrics and Gynecology Hospital from January 2011 to December 2017 were collected. The characteristics of the cases were analyzed.According to the pathogens, the differences between the G~- bacteria group and the G~+ cocci group were compared. Results: The pathogens of perioperative sepsis in gynecology and obstetrics were mostly G~- bacteria, accounting for 71.4%. The white blood cell count, C-reactive protein level and procalcitonin level were significantly increased in patients with sepsis. The fibrinogen(FIB) of the G~- bacteria group was significantly lower than that of the G~+ cocci group(P=0.045). The international normalized ratio(INR) of the G~- bacteria group(P=0.043) and the D-dimer(DD)(P=0.039) was significantly higher than the G~+ cocci group.The differences were statistically significant. 5 patients with septic shock were all G~- bacteria infection. Conclusions:Perioperative sepsis in obstetrics and gynecology is mainly caused by G~- bacteria infection.This type of sepsis has a strong inflammatory response, severe coagulopathy, and septic shock tendency. Early detection, empirical anti-infective therapy, and early application of low molecular weight heparin to prevent disseminated intravascular coagulation(DIC) are critical for improving prognosis.
引文
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[11]艾宇航,张丽娜,龚华,等.低分子肝素治疗脓毒症的前瞻性临床研究[J].中国危重病急救医学,2005,17(12):736-739.
[12]张天翼,卢艳萍,余方宇.低分子肝素对肺炎合并脓毒症患者凝血和内皮细胞功能的影响[J].中国现代医生,2018,56(12):45-47.
[13]何丹,主有峰,王珊,等.低分子肝素对脓毒症患者预后及出血风险的Meta分析[J].中国感染控制杂志,2018,17(8):670-678.
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[15]王进,肖永红.2006-2007年Mohnarin血流感染病原菌构成及耐药性[J].中华医院感染学杂志,2008,18(9):1238-1242.
[16]李耘,吕媛,郑波,等.中国细菌耐药监测研究2015-2016革兰氏阳性菌监测报告[J].中国临床药理学杂志,2017,(23):2512-2542.
[17]金涛,田卓民.血流感染的病原学及诊断进展[J].继续医学教育,2016,30(7):99-101.
[18]周翔,刘大为.脓毒症抗感染治疗新5R原则[J].中国医刊,2018,53(6):581-584.
[2]Dellinger RP,Levy MM,Carlet JM,el al.Surviving Sepsis Campaign:international guidelines for management of severe sepsis and septic shock:2008[J].Intensive Care Med,2008,34(1):17-60.
[3]中国医师协会急诊医师分会,中国研究型医院学会休克与脓毒症专业委员会.中国脓毒症/脓毒性休克急诊治疗指南(2018)[J].临床急诊杂志,2018,19(9):567-588.
[4]Rhodes A,Evans LE,Alhazzani W,et al.Surviving Sepsis Campaign:International Guidelines for Management of Sepsis and Septic Shock:2016[J].Intensive Care Med,2017,43(3):304-377.
[5]吴志恒,郭玉霞,卜婧,等.革兰阴性菌和革兰阳性菌血流感染危重患者中致炎症反应的比较[J].中国感染与化疗杂志,2012,12(1):27-31.
[6]Abe R,Oda S,Sadahiro T,et al.Gram-negative bacteremia induces greater magnitude of inflammatory response than Gram-positive bacteremia[J].Crit Care,2010,14(2):R27.
[7]王绍鸣,张才明.细菌性血流感染致脓毒症患者血清PCT、CRP及内毒素水平变化及临床意义[J].解放军医药杂志,2018,30(1):53-55.
[8]刘坤贺,张春美.血清降钙素原对革兰阴性或革兰阳性菌血流感染的诊断价值[J].临床肺科杂志,2018,23(4):663-665.
[9]钟昌宝,王兰芳,王必管.C-反应蛋白和血清降钙素原及内毒素水平对革兰阴性菌血流感染致脓毒症患者早期诊断的应用价值[J].河北医药,2018,40(16):2420-2423.
[10]Okamoto K,Tamura T,Sawatsubashi Y.Sepsis and disseminated intravascular coagulation[J].J Intensive Care,2016,4:23.
[11]艾宇航,张丽娜,龚华,等.低分子肝素治疗脓毒症的前瞻性临床研究[J].中国危重病急救医学,2005,17(12):736-739.
[12]张天翼,卢艳萍,余方宇.低分子肝素对肺炎合并脓毒症患者凝血和内皮细胞功能的影响[J].中国现代医生,2018,56(12):45-47.
[13]何丹,主有峰,王珊,等.低分子肝素对脓毒症患者预后及出血风险的Meta分析[J].中国感染控制杂志,2018,17(8):670-678.
[14]Hidron AI,Edwards JR,Patel J,et al.NHSN annual update:antimicrobial-resistant pathogens associated with healthcareassociated infections:annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention,2006-2007[J].Infect Control Hosp Epidemiol,2008,29(11):996-1011.
[15]王进,肖永红.2006-2007年Mohnarin血流感染病原菌构成及耐药性[J].中华医院感染学杂志,2008,18(9):1238-1242.
[16]李耘,吕媛,郑波,等.中国细菌耐药监测研究2015-2016革兰氏阳性菌监测报告[J].中国临床药理学杂志,2017,(23):2512-2542.
[17]金涛,田卓民.血流感染的病原学及诊断进展[J].继续医学教育,2016,30(7):99-101.
[18]周翔,刘大为.脓毒症抗感染治疗新5R原则[J].中国医刊,2018,53(6):581-584.
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