PICU重症坏死性筋膜炎诊治分析

目的分析重症坏死性筋膜炎（necrotizing fasciitis，NF）临床特点及诊断治疗要点。方法回顾性分析安徽省儿童医院PICU2007年1月至2013年9月14例NF患儿临床体征、辅助检查、治疗及预后。结果14例患儿中，男8例，女6例，年龄（15．86±10．48）个月，住院天数（29．07±16．30）d，热程（10．64±5．64）d，清创次数（3．07±1．33）次；均有脓毒性休克，5例有多脏器功能衰竭。发病部位：臀部5例，下肢4例，背部2例，会阴部2例，颈部1例；血培养：6例金黄色葡萄球菌（1例耐甲氧西林金黄色葡萄球菌），4例铜绿假单胞菌，3例培养未见明显细菌生长，1例咽峡炎群链球菌。CT均见皮肤及皮下组织水肿，筋膜增厚，11例见软组织气体影。组织活检均确诊为NF；病初表现不典型以局部组织红肿为主，随病情进展患处皮肤苍白伴血疱，后颜色逐渐发紫发黑，部分患儿有皮下握雪感，切开后见筋膜大片苍白坏死；均行切开引流（5例行封闭负压引流持续吸引）、彻底清创、有效抗生素治疗、胶体支持治疗；1期愈合7例（50．00％，7／14），2期植皮4例（28．57％，4／14），死亡3例（21．43％，3／14）；随访2年，6例患儿有局部肢体活动受限。结论NF病情危重，常见于会阴部、腹部及四肢，易导致脓毒性休克，多脏器功能衰竭，革兰阴性杆菌感染临床症状极危重，病死率高。NF需尽早确诊，强有力抗生素使用，积极广泛、彻底地外科清创，充分引流，加强支持对症处理可降低病死率。

Severe neerotizing faseiitis in PICU

Objective To investigate the clinical characteristics,diagnosis and treatment of necrotiz- ing fasciitis （NF）. Methods The authors reviewed and analyzed clinical manifestations, auxiliary examinations, treatments and prognoses of 14 patients who had been diagnosed with NF and hospitalized in the Children＇s Hospital of Anhui province between Jan 2007 and Sep 2013. Results Among the patients included in this study ,eight cases were male and six cases were female. The average age was （ 15.86 ± 10.48 ） month, The time of abnormal temperature was （10. 64± 5.64 ） d, hospital day was （29. 07 ± 16. 30 ） d, numbers of debridements were （3.07 ± 1.33 ） times. All patients had septic shock ,in which 5 cases had multiple organ failure. Diseases were found on hips （5 cases） ,lower limbs （4 cases） ,back （2 cases） ,perineum （2 cases）, and neck （ 1 case）. Blood culture showed staphylococcus anreus in six cases （ 1 case of methicillin-resistant staphylococcus aureus）, pseudomonas aeruginosa in four cases and angina group of streptococcus pneumoniae in one case. No obvious bacteria growth was observed in three cases. CT examinations reflected subcutaneous gas formation in 11 cases but skin and subcutaneous tissue edema and fascial thickening in all cases. All cases of NF were further confirmed with soft tissue biopsies. Early symptoms resembled those of cellulitis. As the diseases progressed, other symptoms appeared such as skin ulceration, bullae formation and gas formation in the tissues. All patients were treated with surgical debridements （vacuum sealing drainage continuous drain- age in 5 cases）, appropriate antibiotic coverage and colloid supporting treatments. Seven patients were healed （50. 00% ,7/14） ,four had skin grafts （28. 57% ,4/14） and 3 died（21.43% ,3/14）. Six cases were found having limited physical activities in two year follow-up visits. Conclusion NF is a rare but potentially fatal disease. It is commonly found on the perineum, abdominal wall and extremities. NF can easily lead to septic shock and multiple organ failure. Early detection, surgical debridement and proper drainage along with appro- priate antibiotic coverage can decrease mortality rates.