损伤控制技术.ppt

* * * * * ml * ml * ml * ml * ml * ml * ml * ml * ml * ml * ml * ml * ml * ml * * 4. DCO 是否使局部感染危险性增加？ Bhandari M. Evidence-Based Orthopedics. 2012, pp 653 Van den Bossche MR ,et al (1995)： 多发伤 股骨干骨折外固定架固定 — 安全 + 感染并发症低（浅部或深部） Harwood PJ ,et al (2006)：174 例股骨干骨折 DCO 与 一期确定性治疗 比较，感染率相同 ( ∽4.5%) Scalea (2000), Nowotarski(2000) : DCO 与 ETC 比较，感染率无显著差异 钉道污染随时间延长而增加, 伤后14天后更换为髓内钉有感染风险 Harwood (2006) There are some evidence that DCO is associated with an increased risk of local infection. In view of the inflammatory burden, conversion to a definitive, biomechanical superior implant should not be performed before days 5-7 after trauma. However, due to an increased risk of local pin site contamination it is recommended that the conversion should be performed before day 14. [overall quality: moderate ] 小结： 有部分研究显示：DCO 能使局部感染危险性增加。 由于存在炎症，伤后5-7天内不宜更换为确定性治疗、生物力学性能优的内植物。但因局部钉道污染危险性增加，应在伤后14天内更换为内固定。（测定IL-6） Bhandari M. Evidence-Based Orthopedics. 2012, pp 653 4. DCO 是否使局部感染危险性增加？ DCO reduces the primary operative burden by reducing intraoperative inflammation, blood loss, operation time. This is of minor importance in stable patients but has clinical relevance for critical patients in the initial treatment phase. These patients should be managed with external fixators which should be converted to a definitive fixation method within 14 days after trauma. DCO通过减少术中炎症、首次手术时间与失血量 ，以减轻首次手术的负担（减少二次打击）； DCO对稳定病人无价值，但对严重创伤的初期治疗意义重大； 初期外固定架固定的病人，应在伤后14天内更换为确定性的内固定。 Bhandari M. Evidence-Based Orthopedics. 2012, pp 627-635 八、骨科损伤控制（DCO）总结 : 临界病人(borderline patient)临床特征 ISS 40 体温 35度 双侧股骨干骨折 合并胸部伤（AIS 2）的多发伤（ISS 20） 合并腹或骨盆伤、出血性休克（收缩压90mmHg）的多发伤 X线平片示肺挫伤 中或重度脑外伤（AIS 3） 初期肺动脉压 24mmHg，或髓内钉等手术时肺动脉压升高 6mmHg Bhandari M. Evidence-Based Orthopedics. 2012, pp 650 Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in