多学科团队协作治疗胸骨深部伤口感染的临床效果

佟琳; 雷晨佳; 张万福; 韩飞; 陈阳; 张浩; 官浩

doi:10.3760/cma.j.cn501225-20250402-00159

多学科团队协作治疗胸骨深部伤口感染的临床效果

doi: 10.3760/cma.j.cn501225-20250402-00159

佟琳¹,
雷晨佳²,
张万福¹,
韩飞¹,
陈阳¹,
张浩¹,
官浩^1, ,

1.
空军军医大学第一附属医院全军烧伤中心,烧伤与皮肤外科,西安　710032
2.
陕西省军区西安第五离职干部休养所门诊部,西安　710048

基金项目:

陕西省卫生健康科研创新能力提升计划项目 2025PT-03

空军军医大学交叉融合专项资助项目 2024JCO21

详细信息

通讯作者:
官浩,Email：guanhao@hotmail.com

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出版历程
- 收稿日期: 2025-04-02

Clinical efficacy of multidisciplinary team collaboration in the treatment of deep sternal wound infection

1.
Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital of Air Force Medical University, Xi'an 710032, China
2.
Outpatient Department of the 5th Xi'an Veteran Cadres Sanatorium, Shaanxi Military Command, Xi'an 710048, China

Funds:

Shaanxi Provincial Health Commission Scientific Research Innovation Capacity Improvement Program 2025PT-03

Air Force Medical University Interdisciplinary Integration Special Funding Project 2024JCO21

More Information

Corresponding author: Guan Hao, Email: guanhao@hotmail.com

摘要

摘要: 目的探讨多学科团队（MDT）协作治疗胸骨深部伤口感染（DSWI）的临床效果。方法该研究为历史对照试验。根据患者采用的诊疗模式,将空军军医大学第一附属医院烧伤与皮肤外科2022年6月—2023年3月收治的符合入选标准且采用传统单学科主导诊疗模式的23例DSWI患者纳入非MDT组,其中男13例、女10例,年龄（56±11）岁；将该单位2023年4月—2024年5月收治的符合入选标准且采用MDT诊疗模式的25例DSWI患者纳入MDT组,其中男12例、女13例,年龄（54±10）岁。对MDT组患者,于其入院后,由烧伤与皮肤外科、心胸外科、重症医学科、麻醉科、药剂科、营养科、内分泌科、血管外科、检验科、放射科、超声科、输血科及康复科共13个科室的主任医师组成的MDT联合评估病情且制订个体化系统诊疗方案；对非MDT组患者,于其入院后,由烧伤与皮肤外科医师主导诊疗,出现专科诊疗局限时按需申请相关科室医师会诊,汇总会诊意见后制订综合诊疗方案。待2组患者病情稳定后,行胸部伤口彻底清创+单侧或双侧胸大肌肌瓣或者联合腹直肌肌瓣修复术。统计患者感染伤口首次手术至愈合的时间,入院至伤口愈合所接受的手术次数、术中出血量、手术时长,围手术期并发症发生情况、肌瓣修复术后15 d内伤口感染复发情况及相应的并发症发生率、伤口感染复发率,出院时采用患者满意度量表评估的患者满意度评分。结果 MDT组患者感染伤口首次手术至愈合的时间为（12.5±2.8）d,显著短于非MDT组的（16.3±2.7）d（均数差值为-3.8 d,95%置信区间为-5.4~-2.2 d,t=-4.78,P<0.05）。与非MDT组比较,MDT组患者入院至伤口愈合所接受的手术次数及术中出血量均显著减少（Z=-2.54,t=-2.20,P<0.05）,手术时长显著缩短（t=-3.41,P<0.05）。围手术期间,MDT组中1例患者发生伤口延迟愈合,1例患者发生肺部感染；非MDT组中2例患者发生伤口延迟愈合,1例患者发生肺部感染,2例患者形成下肢深静脉血栓。MDT组1例患者、非MDT组4例患者肌瓣修复术后15 d内伤口感染复发,经换药后愈合。2组患者围手术期并发症发生率、肌瓣修复术后15 d内伤口感染复发率比较,差异均无统计学意义（P>0.05）。MDT组患者出院时满意度评分为（97.7±2.4）分,显著高于非MDT组的（95.1±3.5）分（t=3.04,P<0.05）。结论对于DSWI患者,MDT诊疗模式可通过多学科医师联合评估优化治疗方案,显著缩短伤口愈合时间,减少手术次数和术中出血量,并提升患者满意度,且未增加并发症发生风险或伤口感染复发风险,值得临床推广应用。
- 外科伤口感染 /
- 外科皮瓣 /
- 纵隔炎 /
- 胸骨切开术 /
- 多学科团队 /
- 创面修复 /
- 并发症
Abstract: Objective To evaluate the clinical efficacy of multidisciplinary team (MDT) collaboration in the treatment of deep sternal wound infection (DSWI). Methods This study was a historical controlled trial. According to the diagnosis and treatment model adopted by the patients, 23 DSWI patients who met the selection criteria and were treated in the Department of Burns and Cutaneous Surgery of the First Affiliated Hospital of Air Force Medical University from June 2022 to March 2023 using the traditional single discipline led diagnosis and treatment model were included in non-MDT group, including 13 males and 10 females, aged (56±11) years; 25 DSWI patients who met the inclusion criteria and were treated using MDT diagnosis and treatment model in the unit from April 2023 to May 2024 were included in MDT group, including 12 males and 13 females, aged (54±10) years. For patients in MDT group, after admission, the MDT, composed of chief physicians from 13 departments including burns and cutaneous surgery, cardiothoracic surgery, intensive care medicine, anesthesiology, pharmacy, nutrition, endocrinology, vascular surgery, laboratory medicine, radiology, ultrasound, transfusion, and rehabilitation, jointly evaluated the condition and developed personalized plans for systematic diagnosis and treatment. For patients in non-MDT group, the diagnosis and treatment were led by surgeons from department of burns and cutaneous surgery after admission. When specialist care was limited, consultation with physicians from relevant departments were requested as needed, and a comprehensive plan for diagnosis and treatment was formulated after summarizing the consultation opinions. Once the conditions of patients in both groups stabilized, a thorough debridement of the chest wound was performed, followed by repair surgery with unilateral or bilateral pectoralis major muscle flap or combined rectus abdominis muscle flap. The time from the first surgery for the infected wound to healing, the number of surgeries performed from admission to wound healing, intraoperative blood loss, and operation duration, perioperative complications, wound infection recurrence within 15 d after muscle flap repair surgery, and corresponding incidences of complications and recurrence of wound infection were recorded, and the patient's satisfaction score evaluated using the Patient Satisfaction Scale at discharge. Results The time from the first surgery for the infected wound to healing of patients in MDT group was (12.5±2.8) d, which was significantly shorter than (16.3±2.7) d in non-MDT group (with mean difference of -3.8 d, 95% confidence interval of -5.4 to -2.2 d, t=-4.78, P<0.05). Compared with those in non-MDT group, the number of surgeries performed from admission to wound healing and intraoperative blood loss of patients in MDT group were significantly reduced (Z=-2.54, t=-2.20, P<0.05), and the operation duration was significantly shortened (t=-3.41, P<0.05). During the perioperative period, in MDT group, one patient experienced delayed wound healing, and one patient developed a pulmonary infection; in non-MDT group, two patients experienced delayed wound healing, one patient developed pulmonary infection, and two patients developed deep vein thrombosis in the lower limbs. Wound infection recurrence within 15 d after muscle flap repair surgery occurred in one patient in MDT group and 4 patients in non-MDT group, all of whom healed after dressing change. There were no statistically significant differences in the incidence of perioperative complication or wound infection recurrence within 15 d after muscle flap repair surgery between the two groups of patients (P>0.05). The patient's satisfaction score at discharge in MDT group was 97.7±2.4, which was significantly higher than 95.1±3.5 in non-MDT group (t=3.04, P<0.05). Conclusions For DSWI patients, the MDT diagnosis and treatment model can optimize the treatment plan through joint assessment by physicians from multiple disciplines. It significantly shortens the wound healing time, reduces the number of surgeries and intraoperative blood loss, and improves patient satisfaction without increasing the risk of complications or wound infection recurrence, which is worthy of clinical promotion and application.
- Surgical wound infection /
- Surgical flaps /
- Mediastinitis /
- Sternotomy /
- Multidisciplinary team /
- Wound repair /
- Complication
佟琳：论文撰写、分析数据、实施手术；雷晨佳：数据收集、统计分析；张万福、韩飞：病例随访、统计分析、实施手术；陈阳、张浩：数据整理、处理图片、分析数据；官浩：研究指导、论文修改、经费支持

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参考文献(38)

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图 1 双侧胸大肌肌瓣推进对接修复胸骨深部伤口感染患者伤口的效果。1A.入院时伤口伴有大量脓液涌出；1B.入院时CT检查提示胸骨未愈合,胸骨骨质部分破坏（红色箭头指示）,两侧错位对合（绿色箭头指示）,有缺损且胸骨后纵隔内有可疑脓腔（黄色箭头指示）存在（上图显示）,X线片提示原胸骨正中切口由钢丝固定（下图显示）；1C.经过换药及引流3 d后,伤口红肿有所改善；1D.术中打开浅层组织可见大量脓液涌出；1E.术中清创、咬除的坏死胸骨及去除的钢丝；1F.术中彻底清创后胸骨缺损、纵隔暴露,放置冲洗管；1G.术中利用双侧胸大肌肌瓣推进对接填塞胸骨缺损；1H.术后即刻佩戴盔甲式胸带及普通外科胸带固定；1I.术后3周缝合口愈合良好；1J.术后2年,胸骨缝合口处可见轻微凹陷且略低于两侧胸廓

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Table 1. 2组胸骨深部伤口感染患者入院时临床资料比较

组别	例数	性别（例）		年龄（岁,x¯±s）	心脏手术类型（例）			合并症（例）				微生物培养结果（例）
组别	例数	男	女	年龄（岁,x¯±s）	大血管置换术	冠状动脉搭桥术	心脏瓣膜置换术	感染性休克	高血压	2型糖尿病	贫血	阳性	阴性
MDT组	25	12	13	54±10	10	8	7	5	17	8	11	23	2
非MDT组	23	13	10	56±11	7	9	7	3	13	12	5	20	3
统计量值		χ²=0.35		t=-0.68	χ²=0.51			χ²=0.02				χ²=0.01
P值		0.556		0.498	0.777			0.878				0.922
注：对多学科团队（MDT）组患者采用MDT诊疗模式进行管理,MDT联合评估病情且制订个体化系统诊疗方案；对非MDT组患者采用传统单学科主导诊疗模式进行管理,出现专科诊疗局限时按需申请相关科室医师会诊,汇总会诊意见后制订综合诊疗方案

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Table 2. 2组胸骨深部伤口感染患者伤口治疗相关指标比较

组别	例数	感染伤口首次手术至愈合的时间（d,x¯±s)	手术次数[次,M（Q₁,Q₃）]	手术时长（min,x¯±s)	术中出血量（mL,x¯±s）	围手术期并发症发生情况[例（%）]	肌瓣修复术后15 d内伤口感染复发情况[例（%）]	出院时满意度评分（分,x¯±s)
MDT组	25	12.5±2.8	1.7（1.0,2.0）	196±44	315±172	2（8.0）	1（4.0）	97.7±2.4
非MDT组	23	16.3±2.7	2.5（1.0,3.0）	240±44	457±267	5（21.7）	4（17.4）	95.1±3.5
统计量值		t=-4.78	Z=-2.54	t=-3.41	t=-2.20	—	—	t=3.04
P值		<0.001	<0.001	<0.001	0.033	0.237	0.407	0.004
注：对多学科团队（MDT）组患者采用MDT诊疗模式进行管理,MDT联合评估病情且制订个体化系统诊疗方案；对非MDT组患者采用传统单学科主导诊疗模式进行管理,出现专科诊疗局限时按需申请相关科室医师会诊,汇总会诊意见后制订综合诊疗方案；手术次数为入院至伤口愈合所接受的手术次数,术中出血量和手术时长为历次手术累计情况；“—”表示无此项