A case of combined gas gangrene rescue after tibia crushed fracture

Patient, male, 59 years old, 170 cm, 72kg, BMI24.9kg/m2, ASAIIWith "the upper part of the left calf swelling deformities, limited activity 2h" was admitted to the hospitalPagenta, check body: HR98 times / minute, BP134/89mmHg, RR20 times / minute, body temperature 36.5 degrees C, left calf upper part deformity, severe swelling, visible upper part of the calf transverse lysage about 8 cm X 5 cm size, skin defects, blood seepage more, not complete, severe, skin-related blood transport dim, subcutaneous tissue widely peeled, skin defect area see bone fragmentation, flip exposed, covered with soil and other foreign bodies, heavy pollutionCR tablets show: a crushing fracture in the upper part of the left femuron June 26, 2017 in the waist-hard joint downstream detection fracture re-fixation fixation, during which the use of salt water, hydrogen peroxide, iodine volt fluid repeatedly rinsed clean-upOn the 3rd day after surgery, the patient's body temperature increased, the pain of the wound intensified, the wound around the tentacles have the pronunciation, odor, the collection of the secretion of the wound gram staining smear, anaerobic culture, the results show: find a large number of gram-positive bacteria, gas clostridium spores, there is a membraneX-rays of the left lower limb show that the wound muscles have gasthe diagnosisas "combined gas gangrene after an open crushing fracture in the upper section of the upper part of the left tibia fibula"patients into the operating room in an emergencyMask oxygen absorption, monitoring ECG and SpO2, open right elbow is in the venous rehydration, line left artery puncture, monitoring of invasive artery pressure, line right neck vein puncture, monitoring CVPPre-anaesthetic HR90 times/min, BP144/89mmHg, SpO2 94%, CVP10mmHgQuiet note Atropin 0.5mg, Dizosin 5mgAnaesthetic-induced static injection relying on the ester 15mg, Shufentani 20 sg, shun aquku ammonium 10mg line trachea intubationintubation after the patient's HR140 times / minute, BP plummeted to 65/30mmHg, that is, multi-pathway accelerated rehydration, deoxygenation 40 sg repeated static push, dopamine intravenous infusion to 10 sg kg-1 min-1, dorepine s10 ml/h, HR down to 40 times / minute, BP rose to 70/55mmHg reduced to 55/30mmHg, SpO2 fluctuations in 60% to 80%, immediate intravenous epinephrine 1 mg, hemodynamics no improvement, intermittent injection of epinephrine a total of 6 mg, Atropine 3mg, interspronotic 2 mg, hemodynamicgradual gradually improvedExtract blood and plasmablood gas analysis results show: pH7.0, blood lactic acid 1.8mmol/L, K-2.5mmol/L, potassium chloride 1g plus 500ml physiological saline intravenous drip, while giving 5% NaH CO3 100ml slow drip, patient HR102 times/min, BP104/60mmHg, SpO2 94%, hemodynamics gradually maintained a stable, dopamine reduced to 2?g kg-1.min-1Anesthetic maintenance intermittent static push sufffenteni 10 sg, inhalation of 2% heptafluoroether, MAC value of 0.8, target pump injection riffentani 3 to 4 ng / mlSurgery found that the cavity pollution is serious, the whole limb has necrosis tissue, has undergone a clean surgery to treat the integrity and function of the difficult limb, in order to prevent bone non-healing and the spread of toxic blood symptoms throughout the body, with the patient's family consultation carried out a left calf amputation, lasted 4h, bleeding a total of 1500 mlwith 3% hydrogen peroxide repeatedly rinse the wound, continuous rapid rehydration crystal fluid 1500ml, colloid ale fluid 1500ml, input red blood cells 8.5U, plasma 800ml, supplement inglyciunate calcium 2g, urine volume is not much, give psiemia 20mg, urine volume reached 800 mlAfter surgery HR98 times/min, BP124/60mm-Hg, SpO2 95%, removed trachea catheterandie and sent to ICUAfter surgery, the vital signs of patients significantly improved, HR89 times / minute, BP124/62mmHg, SpO2 98%, full body support treatment, appropriate blood transfusion rehydration, to maintain the daily urine volume of more than 1500 ml, to give a high-nutrition diet andantibioticstreatment, 2 weeks discharged from hospital, good prognosis1 month after the hospital to review, the results of the examination is normal, no abnormal discomfortdiscussion
gas gangrene is a severe myonecine caused by the invasion of the wound of The Clostridium difficile, which is very pathogenic and 15% can invade theof the bloodcauses sepsisThe incubation period of gas gangrene is 1 to 4d, mostly after injury 3dThis case patient has an open history of trauma, the wound appears severe pain, local swelling intensifies, the skin around the wound has a mole pronunciation, according to the screening experiments, X-ray examination, wound secretions, combined with anaerobic bacteria culture confirmed as the lower limb open fracture caused by gas gangrene Early diagnosis of gas gangrene is the key to rescue, and delays can be life-threatening the method of surgery: First, clean- and second, the whole body toxic blood symptoms are serious, the limb can not be retained, need to amputate as soon as possible Patients with acute illness, the prognosis is very poor, if not treated, within a few days will die Anaesthetic treatment measures: pay attention to the assessment of pre-anaesthetic conditions, understand the important organ condition, and coordination with internal and surgical Gas gangrene patients throughout the body of toxic blood symptoms, often combined with infection shock, pre-anaesthetic preparation, anesthesia methods, anesthesia and dose selection focus, while the management during anesthesia , anti-shock, blood transfusion, rehydration, maintain the function of the organs and correct water-electrolyte, acid-alkali balance is also affecting the success of anesthesia success Combined with the condition of the emergency anaesthetic management can choose the following (1) Nerve block anesthesia: suitable for simple upper limb surgery (2) intravertebral anesthesia: for the disease is relatively light, did not cause the symptoms of systemic toxic blood, but hemodynamic instability, hestlebling difficulties and clotting mechanism disorders limit the application of such anesthesia (3) Trachea intubation of full hemp: is the ideal anaesthetic method for patients with gas gangrene In order to avoid delaying the rescue time, the rapid intubation allows the respiratory tract to be smooth and adequate oxygen supply Give dizosin and atropine before anesthesia for analgesic and reduce saliva secretions Patients have toxic blood symptoms, there may be impaired kidney function, choose without kidney removal of the smooth aquor ammonium, with propofol, riffineni and heptafluoreele and other short-acting drugs to maintain anesthesia, to reduce drug build-up in the body For the presence of infection shock, the optional relying ester with less impact on the cycle is available It has been reported that relying on the ester can raise the level of the anti-inflammatory factor IL-10, while inhibiting the production of the inflammatory factor TNF-alpha of endotoxin stimulation, and reduce the damage caused by endotoxins blood vessels endothelial cells The presence of infectious shock, attention to control the amount of drugs, anesthesia should not be too deep Actively replenish blood volume, regulate water electrolyte-acid-base balance disorder, protect kidney function According to the central vein pressure and invasive arterial pressure to give the balance fluid and colloid, increase the amount of urine to improve kidney function At the same time, the continuous pumping of small doses of dopamine 1 to 3 sg kg-1,min-1 dilated renal blood vessels , in the case of blood capacity supplement, to give psiemia 40 to 80 mg, while monitoring blood gas, infusion 5% NaHCO3 1 to 2 ml/kg to correct acidpoisoning, alkaline urine, pay attention to potassium supplementation After surgery, the whole body supports treatment, appropriate blood transfusion rehydration, keeps the urine volume normal, helps to excrete toxins, gives a high-nutrition diet that is easy to digestion and effective
antibiotic treatment In summary, the correct pre-anaesthetic assessment, reasonable selection of anesthesia methods, medication and active and effective diagnosis and treatment measures, directly affect the treatment effect and prognosis of gas gangrene patients