Treatment of Permcath - Related Sepsis in Uremic Patients

尿毒症病人罹患PermCath相關之敗血症的治療

張哲銘(Jer-Ming Chang) ； 蔡哲嘉(Jer-Chia Tsai) ； 黃尚志(Shang-Jyh Hwang) ； 陳鴻鈞(Hung-Chun Chen) ； 顧進裕(Jinn-Yuh Guh) ； 賴永勳(Yung-Hsiung Lai)

《The Kaohsiung Journal of Medical Sciences》 13卷3期 (1997/03) Pp. 155-161

https://doi.org/10.6452/KJMS.199703.0155

摘要

適當的血管通路是接受長期血液透析的尿毒症病人之生命線，有些連毒症病人因為自身疾病的緣故，無法建立可用的動靜脈廔管，而必須從體外建立人工血管通路。Quinton公司出口的PermCath是近年常用來替代動靜脈廔管功能的一種Silicone材質、帶有dacron cuff 之雙腔室透析導管，能夠長期的使用在血液折的病人身上，但是管腔栓塞和感染卻是長期使用PermCath容易遭受的問題。我們在民國八十二年七月到八十四年七月間，總共治療了17位罹患PermCath相關之敗血症的透析患者(6男11女，平均年齡68歲)平均使用PermCath時間為264天。臨床表徵包括透析時發生高燒或寒顫(70.6%)，PermCath穿皮出口處感染(17.6%)或是沒有症狀(11.8%)。全部患者都接受徹底理學檢查、血液生化、尿液痰液培養以及影像學檢查來確沒有其他感染源。他們也都接受從PermCath的兩個導管腔和周邊靜脈的血液培養，只有在(1)導管腔內和靜脈的血液培養出相同菌種，或(2)導管腔內血液培養出細菌，靜脈的血液培養為陰性，但是患者在透析時發生高燒或寒顫症狀，而且(3)排除其他感染來源之後，才判為PermCath相關之敗血症。培養結果有7/17是Staphylococcous sp. , 5/17 Pseudomonas sp. ,. 4/17 Enterobacter sp. , 1/17 Streptococcus sp.。我們對PermCath相關之敗血症治療有兩種方法是：第一組七人，只接受經靜脈抗生素治，不拔除導管。第二組十人，同時將抗生素灌入並停留在導管腔內以侑經靜脈注射治療，每24小時置換停留在導管腔內的藥物。兩組病人在治療敗血症期間仍使用原有PermCath繼續透折，並且每星期做一次血液培養確認感染是否已經清除。第一組病人中，有二人因為未能控制嚴重敗血症而死亡，其他五人不但感染痊癒而且都保留了原有PermCath。第二組病人中，只有一位在三星期的治療後仍呈現陽性血液培養結果，所以最後還是把PermCath拔掉，至於其餘九人不但感染痊癒而且都保留原有PermCath。
我們的結論是(1)把適當抗生素灌入並停留在導管腔內及及經靜脈注射治療可以很有效的治癒導管相關之敗血症，而且可以保留PermCath以供繼續血液透析的使用。(2)只給予靜脈抗生素治療同樣可以治癒大部分的敗血症，但是應該要注意敗血症的控制情形，必須以血液培養以及細心觀察臨床狀況來評估療效。不管用那一種方法治療感染，如果敗血症的控制形不理想，就該考慮拔管以根除感染源。

並列摘要

Patients who use PermCath as the vascular access for long-term hemodialysis are occasionaslly confronted with catheter-related infections. Recently, we have treated 17 patients suffering from PermCath-related sepsis. The clinical presenting features were leukocytosis in 14/17, high fever and shaking chill during dialysis in 12/17, and signs of exit site infection in 3/17. No shock was found. All patients received clinical evaluation to exclude infection sources other than from blood and inside the catheter, such as pulmonary, genitourinary, hepatobiliary and cutaneous systemse. Blood drawn from both PermCath and peripheral vein was sent for bacterial culture. Bacterial culture of the blood samples from PermCath reveabled Staphylococcus sp. In 7/17, Pseudomonas sp. In 5/17, Enterobacter sp. In 4/17, Streptococcus sp. In 1/17. Fourteen blood samples from peripheral vein showed positive culture resultsd identical to those from PermCath, but negative study were noted in three other patients. The patients were divided into two treatment groups: Group I: systemic antibiotics without PermCath removal in 7, Group II: “locked-in” retention in addition to systemic anti-biotics in 10. Antibiotics were empirically chosen according to bacteriological studies. In the “locked-in” retention treatment, antibiotics were retained into both the inflow and outflow PermCath lumens in the exact volume of each lumen for 24 hours. Theantibiotics solutions were replaced on a daily basis. The same antibiotics were also given intravenously. Duration of treatment depended on clinical progression and follow-up blood culture results and ranged between 13 and 24 days. The schedule of dialysis was not changed through the period of PermCath-related sepsis. The sepsis was cured in all group II cases but not in 2 of group I and resulted in mortality in these 2 patients. The PermCaths were preserved in 5/7 in group I with two mortality cases and all except one preserved in group II patients without mortality. We suggested that “locked-in” retention in addition to systemic antibiotics is the treatment of choice for the patients with PermCath-related sepsis. This method also preserves the functional integrity of PermCath, which is the lifeline vascular access of the patients with exhausted native vessels.

並列關鍵字

PermCath ； catheter-related sepsis ； uremia