Sepsis and Acute Acalculous Cholecystitis in Association with Major Burn - A Case Report

大面積燒傷患者合併急性非結石性膽囊炎及敗血症－病例報告

吳俞鋒(Yu-Feng Wu) ； 黃慧夫(Hui-Fu Huang) ； 劉昌杰(Tom-J Liu) ； 張哲瑋(Che-Wei Chang) ； 莊樹揚(Shu-Yang Chuang) ； 楊永健(Eng-Kean Yeong) ； 戴浩志(Hao-Chih Tai)

《臺灣整形外科醫學會雜誌》 26卷1期 (2017/03) Pp. 117-123

摘要

Background: Formosa Fun Coast Dust Explosion Disaster in Taiwan on June-27-2015 had yielded large casualties with burn injuries. Approximately 499 victims suffered from burn injury in this event. After initial resuscitation and wound management, infection in any form may appear to be the next problem of major burns. Burn patients are functionally immunocompromised, who are vulnerable to bacteria or other pathogens from the surroundings or even from normal flora in themselves. In major burns, infection is the leading cause of mortality and morbidity, which is still a difficult topic nowadays. Aim and Objectives: The purposes of this study are to report a complicated major burn case with septic shock and acute acalculous cholecystitis, and to clarify the differences in burn care from general medical care and possible causes of septic shock and acute acalculous cholecystitis. We also aim to improve our clinical practice of such complicated case. Case Presentation: Here, we present a major burn case with 45% of body surface area, who is one of the victim in large casualties of Formosa Fun Coast Dust Explosion Disaster on June-27-2015, complicated with septic shock. His septic shock is categorized as intra-venous catheter related blood-stream infection (CR-BSI) due to prolonged central venous catheter insertion while one month after injury, and followed by acute acalculous cholecystitis (AAC) 4 days later, which is not common in our burn center. Conclusions: Nowadays, most of current burn center settings could barely afford such large casualties. Well trans-disciplinary communication is essential in this situation. Regular central venous catheter replacement in every 3-7 days is routine in burn care, which is not common in other fields. To prevent from acute acalculous cholecystitis, early and persistent enteral feeding is important and post-pyloric feeding should be taken into consideration as soon as needed.

關鍵字

acute acalculous cholecystitis ； major burn ； catheter-related blood stream infection (CR-BSI)

並列摘要

背景：2015年台灣八仙塵爆事件，造成約499人燒燙傷，共計15人死亡。在大面積燒傷患者，各種形式的感染是治療中後期造成死亡以及各種併發症之一大主因。目的及目標：強調燒燙傷治療與一般急重症臨床治療之差異，以及討論大面積燒傷患者發生敗血症及急性非結石性膽囊炎之可能致病機轉和臨床處理層面上之改善方式。病例報告：一位25歲男性八仙塵爆傷患，全身共45%燒燙傷面積，於治療約一個月傷口穩定後，發生中央靜脈導管放置過久所導致之導管相關菌血症及敗血性休克，於四日後，又併發急性無結石性膽囊炎合併敗血性休克、急性腎衰竭、凝血功能異常，接受廣泛性抗生素治療、管路更換、短期腎臟替代療法後方逐漸康復。結論：面對大量燒傷傷患，須注意燒燙傷治療與一般急重症治療之差異點，包括每3到7日需更換中央靜脈導管、燒燙傷敗血症定義之差異等。定時且有效的與各協助治療單位進行跨科部會議溝通，以減少不必要之歧異發生。大面積燒傷患者處於一個免疫低下之狀況，來自環境或甚至是自身的細菌都可能演變成可能的致病菌而造成嚴重的感染甚至致命。如何預防各種形式感染的發生，包括按時更換管路、早期清創早期傷口關閉、持續的腸道營養等方式，是大面積燒傷患者中後期治療所面臨的一大課題。