感染性休克治疗中并发手足缺血性坏死的临床分析

Clinical analysis of hand and foot ischemic necrosis during septic shock treatment

目的报道感染性休克治疗过程中并发手足缺血性坏死的临床病例,初步探讨其原因、特点及治疗方法。方法通过对2016年11月-2020年9月收治的4例感染性休克治疗过程中并发手足缺血性坏死患者的感染指标、抗生素应用、抗凝时机、血管活性药物应用等方面的分析,总结其特点及可能诱发的原因,并从手外科角度进行手术治疗。结果本组病例在控制感染性休克的同时均大剂量应用升压药物维持血压,在发现手足血液循环较差后均给予抗凝药物应用,其中1例坏死累及前足,行走不稳,需要假肢辅助,余病例坏死均发生在指(趾)体。术后随访6~18个月,平均10个月,4例患者生命体征均平稳,根据中华医学会手外科学会制定的《手功能评定标准》及临床上广泛应用的Kuyvenhoven足功能-5分评分量表综合评定残肢功能:优1例,良2例,可1例。残肢外形良好,残留肢体功能得到最大程度的恢复。结论感染性休克治疗过程中并发手足缺血性坏死可能与升压药物的应用有关,低浓度、中小剂量升压药物升压效果不好时,不要急于增加剂量,如升压效果满意后应及时减停;手足肢端一旦出现花癍、瘀紫、冰凉,便会很快发生坏死,在积极控制感染、改善微循环的同时,临床上在尚未确定出现广泛性出血时应早期应用肝素改善高凝状态,一旦发生坏死迹象,很难逆转;坏死组织清除及残端修整是治疗感染性休克并发手足缺血性坏死最安全有效的手术治疗方式。

Objective To report the clinical phenomenon of hand and foot ischemic necrosis during septic shock treatment,and to discuss its cause,characteristics and treatment.Methods Summarized 4 cases of patients with hand and foot ischemic necrosis during septic shock treatment in our department from November 2016 to September 2020.At the same time,through the analysis of its infection index,antibiotic application,anticoagulant time,vasoactive drug application and other aspects,summarized their characteristics and possible causes from the perspective of hand surgery for surgical treatment.Results Those 4 patients were given large doses of antihypertensive drugs to maintain blood pressure while controlling infection and anti-shock,and were given anticoagulant drugs after poor extremity circulation was found.One patient had acral necrosis involving forefoot,which required prosthesis for unstable walking,and the other 3 patients had necrosis in finger(toe)body.Postoperative follow-up was 6-18 months,with an average of 10 months,and the vital signs of 4 patients were stable.According to the Hand Function Evaluation Standard developed by The Hand Surgery Society of The Chinese Medical Association and the Kuyvenhoven foot function-5 score scale widely used in clinical practice,the residual limb function was evaluated comprehensively:excellent in 1 case,good in 2 cases and fair in 1 case.The residual limb was in good shape and the residual limb function can recover to the maximum extent.Conclusion The complication of patients with septic shock may be four-extremity necrosis,the cause of which may be related to the use of antihypertensive drugs:low concentration,small and medium doses of antihypertensive drugs are not highly effective in raising blood pressure,so do not rush to increase the dose immediately when treating,such as the drug should be promptly reduced or stopped after the antihypertensive effect is achieved.Once tinea-versicolor,bruised,and cold extremities appear,necrosis will occur quickly.Therefore,while actively controlling infection and improving microcirculation,heparin should be applied clinically early to improve hypercoagulation before widespread bleeding is identified,because once signs of necrosis occur,it is difficult to reverse.The safest and most effective surgical treatment for extremity necrosis complicated by septic shock is the removal of necrotic tissue and repair of the stump.