人类免疫缺陷病毒阳性患者骨质疏松椎体压缩骨折围手术期治疗和防护

Perioperative treatment and protection in human immunodeficiency virus infected patients with osteoporotic vertebral compression fracture

目的 探讨人类免疫缺陷病毒（HIV）阳性患者骨质疏松椎体压缩骨折的围手术期治疗与防护相关问题.方法 回顾性分析2010年2月至2015年12月收治的骨质疏松椎体压缩骨折行经皮椎体后凸成形术（PKP）治疗的患者206例,其中HIV阳性患者13例.HIV阳性患者术前常规检测血常规、生化指标、肝肾功能、凝血功能、CD4＋T淋巴细胞计数和病毒载量,评价患者一般情况,给予高效抗逆转录病毒治疗（HAART）,合理应用抗生素以及营养支持、免疫调节药物治疗;术中严格执行预防职业暴露相关防护规范化流程,应用一次性手术防护服：防护面罩、药物夹层手套/双层手套、防渗透手术衣、防护靴套等.观察患者术后并发症、免疫功能与营养状况变化,监测医务人员发生职业暴露情况.随访PKP治疗后伤椎前缘高度、疼痛视觉模拟量表（VAS）评分及Oswestry功能障碍指数（ODI）情况.结果 13例HIV阳性患者手术过程顺利,无骨水泥渗漏、毒性反应发生.12例手术切口一期愈合,发生切口浅部感染l例,经清创后愈合.无死亡病例.术后即刻和末次随访时伤椎椎体前缘高度、VAS评分、ODI评分较术前均得到显著改善,差异均有统计学意义（P＜0.05）.末次随访时的伤椎椎体前缘高度、VAS评分、ODI评分与术后即刻时比较差异无统计学意义（P＞0.05）.11例营养不良HIV阳性患者进行围手术期营养支持及调节免疫干预治疗,干预后CD4＋T淋巴细胞计数、白蛋白（ALB）、血红蛋白（Hb）较干预前均有显著提高[（289.00±54.29）×106/L比（237.25±72.70）×106/L、（38.04±5.17） g/L比（33.73±7.16） g/L、（112.87±15.54） g/L比（100.68±18.95）g/L],差异有统计学意义（P＜0.05）.血小板计数、白细胞计数干预前后比较差异无统计学意义（P＞0.05）.医务人员发生职业暴露2例.依照职业暴露后预防处理预案,所有医务人员均未发生HIV感染.结论 对HIV阳性骨质疏松椎体压缩骨折患者采取适当的围手术期治疗措施,PKP手术同样可以取得较好的手术疗效,围手术期医务人员应严格执行职业暴露防护规范化流程,可以减少职业暴露的发生,安全性较高.

Objective To investigate the effect of perioperative treatment and protection in human immunodeficiency virus （HIV） infected patients with osteoporotic vertebral compression fracture by percutaneous kyphoplasty （PKP）.Methods From February 2010 to December 2015,206 cases with osteoporotic vertebral compression fracture treated by PKP were admitted,including 13 HIV infected patients.Blood routine,biochemical indexes,liver and kidney function,blood coagulation function,immune index and preoperative nutritional status were detected before operation.Highly active antiretroviral therapy （HAART）,reasonable antibiotics,nutritional and immune support were given to the HIV infected patients.Standardized operation process and meticulous operative manipulation were applied during operation.The prevention of occupational exposure protection standardization process was strictly enforced.The postoperative complications,improvement of immune function and nutritional status,vertebral height,VAS,ODI and exposure occupation of medical personnel were observed.Results All 13 HIV infected patients had successful operations,without bone cement leakage and toxic reaction.One patient had perficial infection and the others had operative incisionprimary healing.There was no death.The levels of vertebral height,VAS scores and ODI scores were significantly improved after intervention and at the end of follow-up （P ＜ 0.05）,but there were no significant differences between after the intervention and at the end of follow-up （P ＞ 0.05）.Eleven malnutrition patients with HIV infected were received nutritional and immune support,and the levels of CD4 ＋,ALB and Hb were significantly improved：（289.00 ± 54.29） × 106./L vs.（237.25 ± 72.70） × 106/L,（38.04 ± 5.17） g/L vs.（33.73 ± 7.16） g/L,（112.87 ± 15.54） g/L vs.（100.68 ± 18.95） g/L,P ＜ 0.05.The levels of PLT and WBC had no significantly change （P ＞ 0.05）.Two medical personnel had occupational exposure,and none had HIV infection.Conclusions Perioperative adjuvant treatment in HIV infected patients with osteoporotic vertebral compression fracture can achieve satisfactory outcomes.Strict implementation of protective standardization process should be focused.