国外文献：气性坏疽的治疗和处理

Gas Gangrene Treatment & Management
Medical Care

The combination of aggressive surgical debridement and effective antibiotic therapy is the determining factor for successful treatment of gas gangrene.联合使用积极的外科清创术和有效的抗菌药物治疗是成功治疗气性坏疽的决定性因素。

• Antibiotic therapy抗菌药物治疗[list]In animal models, prompt treatment with antibiotics significantly improves survival rates.动物模型中，快速使用抗菌药物治疗可以显著改善生存率。
• Historically, penicillin G in dosages of 10-24 million U/d was the drug of choice. Currently, a combination of penicillin and clindamycin is widely used.[18] 过去，选择的药物是每日使用青霉素G1000-2400U。目前广泛联合使用青霉素和克林霉素。
• Recent studies show that protein synthesis inhibitors (eg, clindamycin, chloramphenicol, rifampin, tetracycline) may be more effective because they inhibit the synthesis of clostridial exotoxins and lessen the local and systemic toxic effects of these proteins.[26] 最近的研究显示，蛋白合成抑制剂（如，克林霉素，氯霉素，利福平，四环素）更有效，因为可以抑制梭菌外毒素的合成，减轻这些蛋白质在局部和全身的毒性反应。
• In spite of increasing clindamycin resistance among anaerobes, cases of clindamycin-resistant C perfringens are exceptional.[27, 28] 尽管厌氧菌耐受克林霉素有上升趋势，但耐克林霉素的产气荚膜梭菌很少。
• A combination of clindamycin and metronidazole is a good choice for patients allergic to penicillin.对青霉素过敏的患者，联合使用克林霉素和甲硝唑是不错的选择。
• A combination of penicillin and metronidazole may be antagonistic and is not recommended. Because other nonclostridial bacteria are frequently found in gas gangrene tissue cultures, additional antimicrobial coverage is indicated.不建议联合使用青霉素和甲硝唑，因为可产生拮抗。因为气性坏疽组织培养经常会发现其他非梭菌，因此也有必要使用其他抗菌药物。
• Although approved for treating complicated skin and soft-tissue infections, newer antibiotics such as daptomycin, linezolid, and tigecycline have not been studied in patients with gas gangrene; therefore, they should not be used as primary antibiotics for treating this condition.虽然建议治疗复杂的皮肤和软组织感染，但新的抗菌药物，如达托霉素、利奈唑胺、替加环素还没有在气性坏疽患者中研究，这些抗菌药物不应作为首选药物。

[*]Intensive care: Patients with gas gangrene frequently have end-organ failure and other concomitant serious medical conditions that require intensive supportive care.[/*][*]Monitoring serum calcium may need special attention when large areas of necrotic fat may lead to its deposition.[25] [/*][*]Adjuvant therapy: Recombinant human activated protein C (drotrecogin alfa activated) has been used as an adjuvant therapy for patients with severe sepsis who scored 25 or more on the Acute Physiology and Chronic Health Evaluation (APACHE II). However, the mortality rate was higher in patients who had single-organ dysfunction and had undergone surgery within 30 days prior to treatment with drotrecogin alfa activated than in control groups (subset analyses of the PROWESS and ADDRESS studies).[29, 30] In addition, aside from the serious bleeding that may be associated with drotrecogin alfa activated, repeated surgical debridement in patients with gas gangrene requires frequent interruption of the continuous infusion of this product. Therefore, the authors do not recommend this adjuvant therapy in the treatment of gas gangrene.[/*][*]Hyperbaric oxygen (HBO) therapy

Since the 1960s, HBO therapy has been used in the United States for the treatment of gas gangrene; however, its use remains controversial.[/*]
• Controlled prospective studies on human subjects have not evaluated the impact of this treatment on survival. One reason for this is the low number of patients with gas gangrene. In addition, the therapeutic effect of HBO is difficult to reliably assess because of a lack of well-designed comparative studies.[31]
• Many retrospective studies report increased survival in patients when HBO therapy is added to treatment with surgery and antibiotics. However, HBO therapy failed to show a survival advantage in 2 retrospective multicenter studies of the treatment of major necrotizing infections .[32, 33]
• Studies of animal models show conflicting reports about enhanced survival associated with HBO therapy. Studies indicate that HBO therapy has a direct bactericidal effect on most clostridial species, inhibits alpha-toxin production, and can enhance the demarcation of viable and nonviable tissue prior to surgery. For these reasons, some authors recommend the use of HBO therapy before the initial debridement, if possible.
• The most common regimen for HBO therapy involves administration of 100% oxygen at 2.5-3 absolute atmospheres for 90-120 minutes 3 times a day for 48 hours, then twice a day as needed.
• In view of the frequent catastrophic outcomes in patients with gas gangrene, HBO therapy is an important adjunct to surgery and antimicrobial therapy, despite the lack of convincing clinical efficacy.
• Potential risks in patients undergoing HBO therapy include pressure-related trauma (eg, barotraumatic otitis, pneumothorax) and oxygen toxicity (eg, myopia, seizures). Other common adverse effects include claustrophobia. Most adverse effects are self-limiting and resolve after termination of HBO therapy .[34]
• Surgical Care[list]Fasciotomy for compartment syndrome may be necessary and should not be delayed in patients with extremity involvement.
• Copious irrigation should be performed with sterile normal saline solutions and/or 3% liquid hydrogen peroxide.
• Debridement of all wounds should be performed as soon as possible, with removal of badly damaged, contaminated, and necrotic tissue, especially in patients who tmight have been contaminated by soil, farm land, or dirty water.
• If the wounds were treated elsewhere and closed, it is safest to reopen them, clean them, and leave them open with negative-pressure wound dressing therapy (if available) or just a sterile dressing.
• Perform daily debridement as needed to remove all necrotic tissue until the wound has clean and healthy granulation tissue.
• Amputation of the extremity may be necessary and life saving.
• Abdominal involvement requires excision of the body wall musculature.
• Uterine gas gangrene following septic abortion usually necessitates hysterectomy.
• If faced with limited resources and extreme conditions caused by natural disasters such as an earthquake and/or tsunami, surgical care with the above-described principles also can be performed with the patient under local and/or regional analgesia.
• Consultations[list]General surgeon
• Orthopedic surgeon
• HBO service specialist, if the facility is available or within proximity
• Infectious disease specialist
• Hematologist or oncologist
• Gastroenterologist, especially for patients recovering from spontaneous gas gangrene

[/list][/list][/list]粗略地翻译了一下，供大家参考。