Nicolau A E, Merlan V, Ciupan R, Brădiş Alexandra, Marin Mihaela, Plugaru G, Marinescu L, Micu B
Clinica de chirurgie, Spitalul de Urgenţă Floreasca, Bucureşti.
Chirurgia (Bucur). 2008 Jan-Feb;103(1):111-5.
We present the case of a 51 years old multiple injured female patient who was transferred from another hospital. She suffered a car accident and at admission, the diagnosis was anterior flail chest with fractured sternum, blunt abdominal trauma with IIIrd grade kidney laceration, multiple extremities fractures, ISS = 50. We performed emergency nephrectomy, surgical fixation of the flail chest and bilateral pleurostomy. Postoperatively the evolution was difficult, she was intubated and mechanically ventilated. We started early enteral nutrition (EEN), at 24 hours with 20 ml/hour Fresubin (Fresenius-Kabi, Bad Hamburg, Germany) and then with 40 ml/hour. In the fourth postoperative day, CT scan identified no supplementary lesions. In the seventh postoperative day, jaundice became apparent and the CT exam identified gas in the retroperitoneum. At surgery, we identified a IInd degree D2 rupture. We practiced duodenal suture, pyloric exclusion, latero-lateral gastro-entero-anastomosis. We passed a naso-gastro-entero-duodenal tube into D2 for active suction and we performed a fine needle catheter jejunostomy. Difficult postoperative evolution, intubated, febrile, with hemodynamic instability. EEN on the jejunostomy at 20-40-60 ml/hour. 10 days after the reoperation, the general condition ameliorated. Enteral nutrition was continued for 22 days after reoperation. The patient was discharged after 44 days. The particularities of this case are the complexity of the traumatic lesions: anterior costal flail chest, left kidney rupture, late duodenal perforation, multiple extremities fractures (APACHE II score = 34). The treatment involved internal pneumatic stabilization and surgical fixation of the flail chest, duodenal suture with pyloric exclusion and fine needle catheter jejunostomy, left nephrectomy. We consider that the use of EEN was of real help in this case and we recommend it in all polytraumatised patients and in all the cases where it can be used.
我们报告一例51岁的多发伤女性患者，她从另一家医院转来。她遭遇了一场车祸，入院时诊断为前胸壁连枷胸伴胸骨骨折、钝性腹部创伤伴Ⅲ级肾裂伤、多肢体骨折，损伤严重度评分（ISS）=50。我们进行了急诊肾切除术、连枷胸手术固定及双侧胸腔造口术。术后病情进展困难，她接受了气管插管和机械通气。我们在术后24小时开始早期肠内营养（EEN），以20毫升/小时的速度输注瑞素（费森尤斯卡比公司，德国巴特汉堡），然后以40毫升/小时的速度输注。术后第四天，CT扫描未发现新增病变。术后第七天，黄疸明显，CT检查发现腹膜后积气。手术时，我们发现十二指肠D2段Ⅱ度破裂。我们进行了十二指肠缝合、幽门旷置、胃空肠侧侧吻合术。我们将一根鼻胃肠十二指肠管置入D2段进行主动吸引，并进行了细针导管空肠造口术。术后病情进展困难患者插管、发热、血流动力学不稳定。通过空肠造口以20 - 40 - 六0毫升/小时的速度进行EEN。再次手术后10天，一般情况有所改善。再次手术后肠内营养持续了22天。患者在44天后出院。该病例的特点是创伤性损伤复杂：前胸壁连枷胸、左肾破裂、迟发性十二指肠穿孔、多肢体骨折（急性生理与慢性健康状况评分系统Ⅱ（APACHE II）评分为34）。治疗包括连枷胸的内部充气稳定和手术固定、十二指肠缝合加幽门旷置及细针导管空肠造口术、左肾切除术。我们认为在该病例中使用EEN确实有帮助，我们建议在所有多发伤患者以及所有可以使用EEN的病例中使用。
