南京“5．7”^192Ir源放射事故患者的临床救治

Medical management of the victim exposed to ^192Ir source at ＂5.7＂ accident in Nanjing

目的 通过对南京＂5.7＂192Ir源放射事故患者的剂量估算、临床表现和医学处理的总结,探讨类似放射损伤的救治技术和发生、发展规律。方法 医护人员询问受照患者的详细病史,进行物理剂量和生物剂量估算,应用红外线热成像仪动态监测损伤部位的温度改变。进行综合分析,确定诊断和治疗方案。治疗上,全身和局部治疗并重,躯体治疗和心理治疗同步,采取综合措施。给予改善微循环、增强免疫功能、营养支持、抗感染、应用粒细胞集落刺激因子（G-CSF）及对症治疗等进行全身治疗;局部治疗包括镇痛、换药、清创及两次肌皮瓣移植术、脐带间充质干细胞（MSCs）输注、负压封闭引流（VSD）等。结果 患者全身生物剂量估算结果为1.51 Gy,物理估算右下肢皮肤最大剂量值约为4 100 Gy,该结果和临床表现一致;患者受照后约40 d平稳进入恢复期;经过378 d的精心救治,右下肢Ⅳ度急性放射性皮肤损伤伤口愈合,但仍存在活动障碍。结论 早期进行局部不均匀照射的生物剂量估算结果与临床诊断相符,结合系统的医学检查指导救治方案的制定;轻度骨髓型急性放射病病程分期不明显,预后较好;局部严重放射性损伤迁延不愈,肌皮瓣移植是治疗的关键,显微外科技术、VSD封闭式引流技术及MSCs输注是手术成功的关键;抗感染、营养治疗及心理疏导对患者全身及局部的康复起到了积极作用。

Objective To explore the treatment technique, occurrence and development patterns of such radiation injuries as in a major radiological accident that occurred in Nanjing on 7th May in 2014, in which a victim suffered mild bone marrow radiation sickness combined with Degree Ⅳ acute radiation-induced skin injury, based on his dose estimation, clinical manifestations and disease treatments.Methods History inquiry in detail, earlier physical dose estimation and biological dose estimation were conducted in conjunction with examination of temperature changes in radiation injured parts by using infra-red thermoimaging. A comprehensive analysis was made on the basis of estimated dose, clinical manifestation, laboratory examination and imaging examination results with a view to preparing the diagnosis and treatment plan. Comprehensive treatment measures were taken for systemic and topical treatments along with synchronous physical- and psycho-therapy. Systemic treatments included microcirculation improvement, immunity enhancement, nutrition support, anti-infection, application of granulocyte colony stimulating factor （G-CSF） and symptomatic treatment, etc. Topical treatments included analgesia, dressing, debridement and twice myocutaneous flap transplantations, umbilical cord mesenchymal stem cells （MSCs） infusion, vacuum sealing drainage （VSD）, etc. Results The biological dose of whole body was estimated to be 1.51 Gy, while the physical dose in right lower limb was about 4 100 Gy. Dose estimates were consistent with clinical manifestations. After 40 d the patient transited smoothly into the recovery period. After 378 d of active treatment, the wound in right lower limb had healed completely but with dysfunction. Conclusions The biological dose estimates made in the early stage after non-uniform local radiation exposure was consistent with the clinical diagnosis. The treatment plan was made after systemic medical examination. There had not been significant staging courses in mild bone marrow form of acute radiation sickness, but had a better prognosis. Severe local radiation injury had a protracted course. The key of treatment lied in myocutaneous flap transplantations, and microsurgery operation, VSD technique and MSCs infusion guaranteed the success of the surgery treatment. Moreover, anti-infection, nutrition support, and psychological intervention also contributed to the recovery the patient.