腹腔感染实施感染源控制措施的治疗策略

Decision making in the source control of intra-abdominal infection

针对腹腔感染,应尽早实施控制措施。伴有脓毒症或脓毒症休克时,应在积极复苏的同时,根据病情选择经皮穿刺引流、开腹手术或腹腔开放疗法。术后可通过炎症反应指标变化和脏器功能障碍是否改善评估治疗效果。全身炎症反应指标除传统的白细胞计数和C反应蛋白外,还应参考更敏感且具特异性的白细胞介素6和降钙素原等。可通过多脏器功能障碍评分评估脏器功能改善情况。血胆红素是反映腹腔感染时肝脏功能的良好指标,胆红素的持续升高提示感染及脏器功能障碍加重。一旦明确抗感染治疗失败,建议考虑再次尽早实施感染源控制措施。再次介入前,应行B超或CT检查以获得感染灶的准确信息。此外,术前或术中应获取脓液标本行细菌培养,以指导术后抗菌药物的使用。

Source control should be performed as soon as possible once the diagnosis of intra-abdominal infection made. Surgical intervention should be considered when resuscitating the intra-abdominal infection with sepsis or septic shock and percutaneous abscess drainage, laparotomy or open abdominal therapy could be considered according to the sepsis severity. Treatment failure may be diagnosed if there is no any improvement in the systematic inflammatory reaction and multiple organ dysfunction. Interleukin 6 and procalcitonin combined with blood white cell count and C-reactive protein could reflect the systematic inflammatory reaction and Sequential Organ Failure Assessment can evaluate if there is any improvement of organ function. Bilirubin is a sensitive indicator of liver function in intra-abdominal infection and its persistent increasing usually means the deterioration of liver function. Once the treatment failure is made, the re-intervention should be performed as soon as possible and B ultrasound or CT should be done before operation to define the precise infected focus. The bacteria information should be retrieved before or during the intervention to guide the postoperative antibiotics usage.