老年特重度烧伤合并脓毒症伴持续低体温的救治

Treatment of extremely severe burn complicated with sepsis and persistent hypothermia in an elderly patient

目的探讨老年特重度烧伤合并脓毒症伴持续低体温的救治经验,提高烧伤外科医师对大面积烧伤伴低体温的重视。方法报道1例老年特重度烧伤合并脓毒症伴持续低体温患者的病程特点及诊治经过。该患者于伤后第5天起反复检出耐碳青霉烯类病原菌,血清炎症相关指标异常增高,于伤后第9、39天2次确诊脓毒症。于伤后第10天起开始持续低体温,并于伤后第17天行植皮术,术中因体温过低致心脏停搏。此后重视低体温的防治,并加强创面处理、抗感染治疗及营养支持等措施。同时以“烧伤”“低体温”“脓毒症”为中文关键词检索万方数据库和中国知网,以“severe burn/major burn”“hypothermia”“sepsis”为英文关键词检索PubMed数据库,检索2010年8月至2021年8月相关文献并分析。结果患者经积极综合救治后,脓毒症得到有效控制,各脏器功能良好,于伤后第33天结束了持续近1个月的低体温,伤后第128天创面基本愈合。检索到特重度烧伤合并脓毒症发生低体温的影响因素及治疗对策的相关文献6篇,研究结果提示烧伤面积大、高龄、感染等是发生低体温的影响因素,采取一系列术前、术中、术后综合保温措施是解决低体温难题的有效途径。结论特重度烧伤合并脓毒症的救治关键在于早期发现、早期处理,重视微生物培养、药物敏感试验和炎症相关指标的连续监测,预判疾病进展,并制定合理诊疗策略;尤其要关注高龄、低体重或营养不良的患者,应及早预防出现低体温。

Objective To explore the treatment experience of senile severe burn complicated with sepsis and persistent hypothermia in the elderly,and to improve the attention of burn surgeons to large area burn accompanied by hypothermia.Methods The course of disease and diagnosis and treatment of an elderly patient with severe burn complicated with sepsis and persistent hypothermia was reported.Carbapenem resistant pathogens were repeatedly detected in the patient on the 5th day after injury,and serum inflammatory-related indicators were abnormally high.Sepsis was diagnosed twice on the 9th and 39th day after injury.Hypothermia began to persist on day 10th day after injury and cardiac arrest due to hypothermia during skin grafting on day 17th day after injury.Since then,attention had been paid to the prevention and treatment of hypothermia,and measures such as wound treatment,anti-infection treatment and nutritional support had been strengthened.Wanfang database and CNKI were searched with the Chinese keywords“burn”,“hypothermia”and“sepsis”,and PubMed was searched with the English keywords“severe burn/major burn”,“hypothermia”and“sepsis”.The related literatures from August 2010 to August 2021 were searched and analyzed.Results The sepsis of the patient was effectively controlled,and the organ function was good.The hypothermia that lasted for nearly a month was ended on the 33rd day after injury,and the wound was healed on the 128th day after injury.Six literatures related to the influencing factors and treatment of hypothermia caused by severe burns combined with sepsis were retrieved.The results suggested that burn area,age,infection,etc were risk factors for hypothermia,and taking a series of preoperative,intraoperative and postoperative comprehensive thermal insulation measures was an effective way to solve the problem of hypothermia.Conclusions The key to the treatment of extremely severe burns complicated with sepsis lies in early detection and early treatment,attaching importance to the microbial culture drug sensitivity test and continuous monitoring of inflammation-related indicators,predicting the disease progression,and formulating reasonable diagnosis and treatment strategies.Attention should be paid to the elderly patients with low body weight or malnutrition especially,should be early prevention of hypothermia.