严重烧伤后深静脉导管相关感染并发颅内多发性脓肿一例ACaseofCerebralMultipleAbscessOccuringWithDeepVeinCatheterRelatedInfectionAfterSeverelyBurnt患者男，36岁，因全身火焰烧伤于伤后3h入院。入院时检查:T36.1℃,P96次/min,R22次/min,患者一般情况可，神志清楚，呼吸平顺，烧伤创面分布于头面、颈，躯干及四肢，创面基底大部分呈黄白色。入院诊断:①烧伤总面积35%,浅II度15%,深II度20%。入院后行右侧股静脉穿刺置管常规液体复苏、创面清创，头面部暴露,四肢及躯干创面外用1%磺胺嘧啶银霜包扎等治疗。入院后20h,患者面颈部、双前臂肿胀明显,自诉喉头有异物感及双手指麻木等不适,遂于局麻下行气管切开,双上肢烧伤皮肤及浅筋膜切开减压术,随后病情平稳。伤后5d在静脉全麻下行“双上肢、左小腿深II度创面15%削痂、自体网状皮移植术”，术后应用头孢哌酮+依替米星抗感染,面部深II度创面,躯干等部位创面继续外用1%磺胺嘧啶银霜隔日换药,创面分泌物未培养出细菌,术后5d,削痂植皮创面换药,皮片成活良好，伤后14d拔除气管套管，拔管后患者呼吸平顺，病情稳定，除右下腹及左足背约1%深II度创面未愈外,其余创面均愈合。治疗过程中,伤后11d开始,患者出现高热,最高达40.1℃,外周血白细胞计数达20.1×109/L,中心粒76%,调整抗生素为美洛西林+依替米星二联抗感染,2d后,外周血白细胞计数下降至11.4×109/L,中心粒细胞86%,体温仍有波动,最高为38.9℃,胸部X-线检查未见双肺有异常改变。伤后15d再次出现寒战、高热，考虑有金黄色葡萄球菌感染可能,拔除右侧股静脉导管并送细菌培养,调整抗菌素为稳可信500mgq6h静脉点滴,再次送检创面分泌物细菌培养及血培养。3d后,静脉导管、创面分泌物及血细菌培养均为耐甲氧西林金黄色葡萄球菌生长（MRSA），体外药物敏感试验对万古酶素敏感，继续静滴稳可信,患者体温有所下降，但渐渐出现神情淡漠、懒言及肢体乏力等症状,静滴稳可信6d后，出现左上肢肌力减退（III级），行颅脑MR检查示：右侧小脑半球及颞叶、额叶见多发片状长T1、T2信号影，境界模糊，压水序列像上呈高信号，增强扫描见明显环行强化或不完全的环形强化，局部脑沟、裂变窄，最大病灶位于右侧颞叶，大小约3cm×2.8cm，两侧大脑，左侧小脑尚可见散在小斑点样强化灶。提示两侧大脑、小脑多发性感染灶，部分脓肿形成，结合临床诊断为烧伤后颅内多发性MRSA感染，部分脓肿形成。转神经内科继续稳可信并加用磷霉素钠抗感染，甘露醇脱水降颅压等治疗，一周后因脓肿破裂出血死亡。译文：Thepatient,male,36yearsold,wassenttohospital3hoursafterhewasburntbyflamealloverhisbody.Examinationonadmission:36.1T℃,P96times/min,R22times/min,patientwasinordinaryconditionwithconsciousmindandsmoothbreath.Theburntwoundspreadsinhead,neck,bodyand4limbs.Thebaseofburntwoundwasmostlyyellowishwhite.Diagnosisonadmission:①Totalburntarea35%,IIdegreesuperficialburn15%,IIdegreedeepburn20%.Afteradmission,thepatientreceivedtreatmentofindwellingcatheterbyrightfemoralveinpunctureconventionalfluidresuscitation,wounddebridement,headandfaceexposure,4limbsandbodywoundboundupexternallywith1%densitysulfadiazinesilverfrost,etc.20hoursafteradmission,patient’sface,neckandbothforearmswereobviouslyswelling.Hecomplainedtherewasmalaisefeelingofforeign-bodysensationinthroatandnumbnessinbothhandsfingers.Sotracheotomy,burntskinofbotharmsandsuperficialfasciaincisionreleasewerecarriedout.Thenthepatient’sconditionwasimproving.5daysafterinjury,15%ofbotharms,leftcalfIIdegreedeepburntwoundscabexcisionandmeshedautogenousskintransplantationwerecarriedoutunderintravenousanaesthesia.Afteroperation,cefoperazoneandetimicinwereusedtopreventinfection,and1%densitysulfadiazinesilverfrostwasstillappliedexternallyinIIdegreedeepburntfacewoundandbodywoundwhichwouldberefreshedonalternatedays.Bacteriawasnotculturedfromwoundsecretion.5daysafteroper...
