肛周坏死性筋膜炎患者的麻醉管理

Anesthetic management of patients with perianal necrotizing fasciitis

目的:通过对肛周坏死性筋膜炎(PNF)患者围术期处理的回顾性分析,探讨此类患者麻醉管理注意事项。方法:收集2013年1月～2017年8月我院坏死性筋膜炎患者98例,对术前感染状态、生命体征、麻醉方式、术中特殊处理和疾病转归进行回顾性分析。结果:所有病例均顺利完成清创引流术,其中90. 8%的患者术前血糖高于5. 6 mmol/L,中位数9. 22mmol/L; 73. 5%患者白细胞升高,白细胞计数中位值13. 76×10~9;麻醉选择包括低位蛛网膜下腔麻醉(33例)、连续硬膜外麻醉(42例)及气管插管全身麻醉(23例); 33. 67%患者(33例)麻醉前施行了中心静脉穿刺置管术与早期液体复苏,围术期血管活性药物使用率32. 65%; 26. 53%患者术后送往ICU,17. 35%患者经历了二次清创,围术期病死率7. 14%;麻醉后血流动力学指标改变有统计学意义(P<0. 05)。结论:PNF患者感染重,并发症多,病死率高,麻醉方式与药物使用应根据具体病情选择,良好的术前准备、液体复苏及血管活性药物合理应用可改善患者血压等生命体征,是影响预后的关键。

Objective:To investigate the attentions to perioperative management of patients with perianal necrotizing fasciitis.Methods:Ninety-eight cases of perianal necrotizing fasciitis treated in our hospital were included from January 2013 to August 2017,and retrospectively analyzed regarding infection status before operation,basic vital signs,anaesthesia mode and special treatment during operation as well as disease outcomes.Results:Lesion debridement and surgical drainage were successfully completed in all patients.Higher preoperative blood glucose(5.6 mmol/L,median 9.22 mmol/L)and elevated white blood cell count(median 13.76×10 9)were seen in 90.8%and 73.5%of the patients,respectively.Analgesic option included low subarachnoid anesthesia in 33,continuous epidural anesthesia in 42 and general anesthesia via tracheal intubation in 23 patients.33.67%patients(n=33)underwent central venous catheterization and early fluid resuscitation before anesthesia.32.65%patients required perioperative vasoactive drugs,and 26.53%were referred to ICU following surgery.17.35%patients were undergone second debridement.Perioperative mortality was 7.14%.Changes of hemodynamic indexes after anesthesia were statistically significant(P<0.05).Conclusion:Patients with perianal necrotic fasciitis can be in severe infection,many complications and high mortality.Anesthesia and drug use should be selected in compliance with the specific condition of patients.Intravenous fluid resuscitation and rational use of vasoactive drugs could significantly improve blood pressure and other vital signs,which are the keys to prognosis.