同步报告病例4（第五回）：没有最烂，只有更烂一个危重足患者保脚经历

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15 10月 2019

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Author : 伤口世界

原创：十六点五中山二院糖尿病足中心

2018年12月9日，

广州马拉松开跑的日子。

寒风夹杂着小雨，

最高温度12°C，

让人默默地把前天还开着冷空调的房间里

放上了电热油汀。

病房一如既往的安静，

而在病床上和细菌斗争的病人

进入了一个关键阶段

虽然没有马拉松的喧嚣

也没有立竿见影的胜负方

但现在的很多决策将直接影响最后的治疗效果

将直接决定是否能够保住病人的脚。

全身方面来看，

目前病人的病情是平稳的

但昨天还有一次短时间的高热

自行退热

从上周三开始一直有腹泻

抗生素在慢慢的减量

现在面临的第一个关键问题是：

是否继续减量全身抗生素？

全身及局部的感染肯定得到了一定的控制，

但是否完全控制，

不能准确评估

（所有炎症指标均未完全正常）

另一方面

二重感染的阴影越来越大

而患者长期用大量抗生素导致的

菌群失调的恶果也愈发明显，

腹胀，没有胃口，不能进食，

更重要的是局部处理的矛盾（见下文）

思前想后

还是决定明天继续降级抗生素

两害相权取其轻。

局部方面看

下图的左足内侧是目前处理焦点。

左足内侧

右足内侧和底部

单纯从照片看，

与右足类似部位相比

肯定还需要继续清创

但其下面就是踝关节的一部分（距跟舟关节）

一旦破坏

轻者关节被感染

重者有可能会导致整个踝关节的崩溃

那左足难保。

如果不清创

如前所述

现在急需减少全身抗生素的应用

而仅仅靠安尔碘纱布填塞

是否能够在抗生素降级的情况下

减少韧带的细菌感染

甚至杀灭细菌

使肉芽组织长起来

不是很有信心。

同样是两害相权取其轻

决定用后一种方法。

一方面我们对于安尔碘杀菌有足够的信心

另一方面

如果万一不行

再清创也不是没有挽回的余地

希望患者运气足够好

使我们的决策是正确的。

真是

谋事在人

成事在天

希望岁月静好，

平稳度过最考验的时期！

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Material and methods

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主任医师、教授、博导，南方医科大学第三附属医院（广东省骨科医院）院长