重度烧伤患儿Meek微型皮片移植失败的原因及治疗措施

Analysis of reasons for failure of Meek micro-skin grafting in children with severe burn and treatment measures

目的分析重度烧伤患儿Meek微型皮片移植失败的原因并观察所采取的治疗措施的临床效果。方法将安徽医科大学第一附属医院烧伤科(下称笔者单位)2012年1月—2018年1月收治的符合入选标准并行Meek微型皮片移植但手术失败的30例重度烧伤患儿纳入植皮失败组,其中男17例、女13例,年龄1~12岁;另任选笔者单位同一时间段收治的符合入选标准的30例行Meek微型皮片移植手术成功的重度烧伤患儿纳入植皮成功组,其中男16例、女14例,年龄1~12岁。回顾性分析2组患儿术前主要治疗措施及效果,Meek微型皮片移植面积及成活率,感染病原菌情况,敏感抗生素的选用情况,术前营养状况、植皮失败组术后存活患儿加强营养支持前后的营养状况,梅雨季节创面感染情况。对数据进行χ2检验、t检验。结果(1)2组入院后行扩容抗休克、气管切开插管、呼吸机辅助呼吸、肢体切开减压等主要治疗措施的患儿数相近(χ2=0、0.016、0.025、0.009,P>0.05),采取上述措施后均达到了纠正休克、预防窒息、纠正呼吸困难、改善肢体末梢循环的效果。(2)植皮成功组患儿Meek微型皮片移植面积为(20.6±2.5)%体表总面积(TBSA),与植皮失败组的(21.2±2.2)%TBSA相近(t=0.534,P>0.05),植皮成功组患儿Meek微型皮片成活率为(79±5)%,显著高于植皮失败组的(26±3)%,t=2.956,P<0.01。(3)植皮成功组30例患儿创面分泌物微生物培养阳性5例(16.67%),其中铜绿假单胞菌2例、大肠杆菌1例、金黄色葡萄球菌1例、曲霉菌1例,无全身感染症状,未行血微生物培养。植皮失败组30例患儿创面分泌物微生物培养阳性30例(100.00%),血微生物培养阳性8例(26.67%);感染病原菌为以铜绿假单胞菌为主[11例(36.67%)]的8种病原菌,其中革兰阴性菌22例(73.33%)、革兰阳性菌11例(36.67%)、真菌6例(20.00%)。(4)30例植皮失败组患儿使用头孢类、糖肽类、碳青霉烯类、四环素类抗生素等10种敏感抗生素,其中亚胺培南使用率最高[9例(30.00%)]。植皮成功组患儿仅使用了头孢他啶等4种敏感抗生素。(5)植皮成功组患儿术前白蛋白、前白蛋白水平分别为(32±4)g/L、(133±41)mg/L,明显高于植皮失败组的(27±4)g/L、(93±35)mg/L(t=5.090、4.064,P<0.01)。植皮失败组术后存活患儿营养支持治疗后白蛋白、前白蛋白水平为(35±4)g/L、(168±49)mg/L,明显高于营养支持治疗前的(27±4)g/L、(94±38)mg/L(t=6.911、6.315,P<0.01)。(6)植皮失败组30例创面感染患儿中9例发生在梅雨季节,6例真菌感染患儿中3例发生在梅雨季节;植皮成功组5例创面感染患儿中2例发生在梅雨季节,唯一的1例真菌感染也发生在梅雨季节。结论重度烧伤患儿Meek微型皮片移植失败的主要原因包括感染因素、营养因素、季节因素等,经加强创面换药、合理使用敏感抗生素控制感染、肠内肠外营养支持,加强通风降低梅雨季节的干扰,效果良好,值得临床推广。

Objective To analyze the reasons for failure of Meek micro-skin grafting in children with severe burns and to observe the clinical effects of the treatment measures.Methods Thirty children with severe burns hospitalized in the First Affiliated Hospital of Anhui Medical University(hereinafter referred to as the author′s affiliation)from January 2012 to January 2018,conforming to the inclusion criteria were included to failed skin graft group.Children in failed skin graft group were performed with Meek micro-skin grafting operation and the operation failed,including 17 males and 13 females aged 1 to 12 year(s).Thirty children with severe burns hospitalized in the author′s affiliation during the same period of time,conforming to the inclusion criteria,were included to successful skin graft group.Children in successful skin graft group were performed with Meek micro-skin grafting operation and the operation succeeded,including 16 males and 14 females aged 1 to 12 year(s).Main treatment measures and effects before operation,area and survival rate of Meek micro-skin graft,infected pathogens status,selection status of sensitive antibiotics,preoperative nutrition status,and wound infection status in plum rain season of children in the two groups,and nutritional status before and after strengthening nutritional support of postoperative surviving children in failed skin graft group were analyzed retrospectively.Data were processed with chi-square test and t test.Results(1)The numbers of children in the two groups performed with main treatment measures of dilatation and anti-shock,tracheotomy intubation,ventilator-assisted respiration,and limb incision decompression after admission were close(χ2=0,0.016,0.025,0.009,P>0.05).After taking the above-mentioned main treatment measures,effects of correcting shock,preventing asphyxia,correcting breathing difficulty,and improving peripheral circulation of limb were achieved.(2)The area of Meek micro-skin grafting of children in successful skin graft group was(20.6±2.5)%total body surface area(TBSA),close to(21.2±2.2)%TBSA in failed skin graft group(t=0.534,P>0.05).The survival rate of Meek micro-skin graft of children in successful skin graft group was(79±5)%,significantly higher than(26±3)%in failed skin graft group(t=2.956,P<0.01).(3)The microbial culture of wound secretion of 5(16.67%)children in 30 patients in successful skin graft group was positive,with Pseudomonas aeruginosa of 2 children,and Escherichia coli,Staphylococcus aureus,and Aspergillus of one patient respectively.As children in successful skin graft group were with no symptom of systemic infection,no blood microbial culture was done.The microbial culture of wound secretion of 30(100.00%)children in 30 patients in failed skin graft group was positive,and blood microbial culture of 8(26.67%)children was positive.The main pathogen was Pseudomonas aeruginosa of 11(36.67%)children in 8 pathogens caused infection with gram-negative bacteria of 22(73.33%),gram-positive bacteria of 11(36.67%)children,and fungi of 6(20.00%)children.(4)Ten kinds of sensitive antibiotics such as cephalosporins,glycopeptides,carbapenems,and tetracyclines antibiotics were used in children in failed skin graft group,of which the use rate of imipenem of 9(30.00%)was the highest.Only 4 kinds of sensitive antibiotics such as ceftazidime were used in 30 children in successful skin graft group.(5)The preoperative levels of albumin and prealbumin of children in successful skin graft group were(32±4)g/L and(133±41)mg/L respectively,significantly higher than(27±4)g/L and(93±35)mg/L in failed skin graft group(t=5.090,4.064,P<0.01).The albumin and prealbumin levels of postoperative surviving children in failed skin graft group after nutritional support treatment were(35±4)g/L and(168±49)mg/L,significantly higher than(27±4)g/L and(94±38)mg/L before nutritional support treatment(t=6.911,6.315,P<0.01).(6)Wound infection of 9 children in 30 children with wound infection in failed skin graft group happened in the plum rain season,and fungi infection of 3 children in 6 children with fungi infection happened in the plum rain season.Wound infection of 2 children in 5 children with wound infection in successful skin graft group happened in the plum rain season,and the only one children with fungi infection happened in the plum rain season.Conclusions The main reasons for the failure of Meek micro-skin grafting in children with severe burns include infection,nutrition,and season factors,etc.Measures of strengthening wound dressing change,reasonable use of sensitive antibiotics to control infection,internal and external intestinal nutritional support,and reducing disturbance of the plum rain season by enhancing ventilation are effective and worthy of clinical promotion.